Medallion 4.0 Managed Care Services Agreement - Virginia

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COMMONWEALTH OF VIRGINIADEPARTMENT OF MEDICAL ASSISTANCE SERVICESMedallion 4.0Managed Care Services AgreementCONTRACT TO PROVIDE MANAGED CARE SERVICESFOR THE MEDICAID and FAMILY ACCESS TO MEDICALINSURANCE SECURITY (FAMIS) PROGRAMSJULY 1, 2020 – JUNE 30, 2021Medallion 4.0 Managed Care Contract SFY21v31

CONTENTSContents . 21. Definitions and Acronyms . 151.1 Definitions. 151.2 Acronyms . 482.Scope of Contract . 32.3.A2.3.B2.3.C2.3.D2.42.52.63.Applicable Laws, Regulations, and Interpretations . 51Covered Populations . 52Parents, Caretaker Relatives, and Dependent Children . 52Infants, Children, and Youth . 52Pregnant Women . 52Children and Youth with Special Health Care Needs (CYSHCN) . 53Foster Care . 53Medicaid Expansion Population . 54FAMIS . 54New Populations . 54Member Third-Party Liability . 54Comprehensive Health Coverage . 54Workers’ Compensation . 55Estate Recoveries . 55Other Coverage . 55Commitment to Department Goals and Initiatives . 56Department Oversight. 56Responsiveness to the Department . 56Medallion 4.0 Requirements to Do Business . 3.6.F3.6.G3.6.H3.6.I3.6.J3.6.K3.7Licensure and Solvency . 57Certification . 57Accreditation . 57Milestones for New Managed Care Organizations. 58Qualified Health Plan Reporting . 58Ownership and Control Interest . 58Organizational Structure . 59Company Background History . 60Virginia Based Operations. 60Dedicated Project Director and Project Manager . 60Medical and Behavioral Health Leadership Staff. 61Compliance Officer . 61Provider Relations Staff. 61Program Integrity Lead . 61Encounter Data Manager . 62CYSHCN Care Coordinator . 62Key Personnel Changes . 62Department Authority to Remove Staff. 62Changes to Contractor Organizational Structure and Operations . 63Medallion 4.0 Managed Care Contract SFY21v32

3.83.8.A3.93.103.10.A4.Provider Network Management. 84.8.A4.94.104.114.125.Proposed Acquisition and Purchase/Sale of Health Plan . 64NCQA Notification Requirements . 65Readiness Review and Annual Requirements for Review . 65Departmental Meetings. 66Meetings with State Government Agencies . 66Network Adequacy Standards . 66Provider Network Composition . 67Network Establishment & Maintenance . 67Notification to the Department . 68Admission Privileges . 68Network Provider File Submissions . 68Enrollment Broker and Other DMAS Contractors . 68Complete Provider File to Department . 68Network Sufficiency Determined by the Department . 69Network Provider Classes . 69Provider Network Data Requirements . 70Provider Recruitment and Selection . 70Adequate Resources . 71Panel Participation Prohibited . 71Out-of-State Providers . 71Provider Licensing and Certification Standards . 71Credentialing/Recredentialing Policies and Procedures . 71Credentialing of Behavioral Health Providers. 72Credentialing of Early Intervention Providers. 72Community Mental Health Rehabilitation Services Provider Qualifications . 72Provider Enrollment into Medicaid . 73Reimbursement of New Provider Applicants . 74Excluded Entities/Service Providers . 74Access to Care . 75Choice of Provider Standard. 75Member Travel Time and Distance Standards . 75Exceptions to Access Standards . 76Policy of Nondiscrimination . 76Member Access to Reasonable Accommodations and Accessible Equipment . 76Member-to-PCP Ratios. 77Inpatient Hospital Access . 77Twenty Four-Hour Coverage. 77Appointment Standards . 77Appointment Standards and Member’s Health Condition . 77Maternity Care Appointment Standards . 78Emergency Services Coverage . 78Medical Help Line Access Standards . 78Continued Network Adequacy for Medicaid Expansion Population . 79Provider Engagement . 79Medallion 4.0 Managed Care Contract SFY21v33

A5.11.B5.11.C6.Provider Contracting. 79Provider Agreements . 79Anti-Discrimination . 81Provider Identification Numbers (NPIs). 81Subcontractor Management & Monitoring. 81Review Requirements for Subcontractors . 82Delegation and Monitoring Requirements . 82Use of Third Party Administrator (TPA) . 83Firewalled Staff & Facilities. 84Provider Education and Training . 84Provider Services . 85Provider Call Center . 85Monitoring by the Contractor . 85Emergency Department Assistance Line . 85Provider Satisfaction Survey . 85Provider Payment Processing . 86Provider Termination . 87Notice to the Department . 87Physician Incentive Plan . 88Protection of Member-Provider Communications . 89Provider Inquiry Performance Standards & Report . 89Provider Advisory Committee . 90Contractor Referral Responsibilities . 90Referral Requirements . 90Relationships with Key State Partners. 90Availability of Other State Programs and Services . 91Member Eligibility, Enrollment, and General Responsibilities . 2.D6.36.3.A6.3.B6.3.C6.3.D6.46.4.AGeneral. 92Enrollment Determination . 92Contractor Responsibilities. 92Coverage for Services . 93Capitation Payments . 94Effective Periods. 94Enrollment . 94Eligibility for Enrollment . 94Enrollment Exclusions. 94MCO Enrollment Limit by Region . 96Delay of Enrollment Due to Member Hospitalization. 96MCO Assignment . 96Intelligent Assignment . 96Member Choice . 97Open Enrollment. 97MCO Change for Cause . 98Special Populations. 99Newborns . 99Medallion 4.0 Managed Care Contract SFY21v34

6.4.B6.4.C6.56.5.A6.5.B6.5.C6.5.D7.Foster Care & Adoption Assistance Children and Youth. 101Medicaid Expansion Population . 102Member Primary Care Providers (PCP) . 102PCP Assignment . 102Member Choice of PCP . 102Providers Qualifying as PCP . 103Indian Health Service (HIS) Providers . 103Member Outreach and Marketing Services . K7.6.L7.6.M7.6.N7.6.O7.6.PGeneral Requirements . 104Adequate Written Descriptions to Members . 104Annual Marketing Plan . 104Materials in Advance of Events. 105Marketing and Informational Material Requirements . 105Flesch Readability Scores . 105Sanctions . 105Use of Electronic and Social Media . 105Distribution of Marketing Materials . 105Permitted Marketing and Outreach Activities . 106General Public . 106Through the Department . 106Pre-Approved Mail Campaigns . 106Potential Member Request. 106Community Sites . 106Health Awareness/Community Events . 106Health Screenings . 106Wellness and Member Incentive Programs Report . 106Promotional Items or “Giveaways” . 107Member Healthy Incentives. 107Prohibited Marketing and Outreach Activities . 107Certain Informational Marketing Activities . 107“Cold-Call Activities” . 107Direct Mailing. 108Home Visits/Direct Marketing or Enrollment . 108Financial Incentives . 108Prospective Member Marketing . 108Improper Use of DMAS Eligibility Database . 108Targeting on Basis of Health Status . 108Contacting Members After Disenrollment Date . 108Marketing a Rebate or Discount . 108DSS Offices . 108Statements of Endorsement (Government). 109Enroll to Keep Benefits . 109Renewal of Medicaid Benefits/Reason for Disenrollment . 109Influence Enrollment . 109Direct Marketing to Any Child Under Nineteen (19) Years of Age . 109Medallion 4.0 Managed Care Contract SFY21v35

7.7Communication Standards . 1097.7.A Member Notification . 1117.8New Member Material Requirements . 1117.8.A Required Membership Materials . 1117.8.B Network Provider Directory . 1137.8.C Member Handbook . 1147.9Mailing Requirements for Member ID Cards and New Member Packets . 1147.9.A Mid-Month 834 – Member Identification Card Only. 1147.9.B End of Month 834 – All New Member Packets & Member Identification Cards forThose New Members Not on Mid-Month . 1157.10Member Handbook . 1157.10.A Member Handbook Contents . 1167.10.B Member Eligibility . 1167.10.C Procedures to be Followed if the Member Wishes to Change MCOs . 1167.10.D Choosing or Changing a PCP . 1167.10.E Making Appointments and Accessing Care . 1167.10.F Member Rights . 1177.10.G Member Services . 1177.10.H Emergency Care . 1177.10.I Member Identification Cards . 1187.10.J Member Responsibilities . 1187.10.K MCO Responsibilities. 1187.10.L Grievances and Appeals [42 CFR Part 438.10 Subpart F)] . 1187.10.M Interpretation and Translation Services . 1197.10.N Program Referral and Service Changes . 1197.10.O MCO Plan Formulary . 1197.11Member Rights . 1207.11.A Receive Information . 1207.11.B Respect. 1207.11.C Information on Available Treatment Options . 1207.11.D Participate in Decisions . 1207.11.E Be Free From Restraint/Seclusion . 1207.11.F Request/Receive Medical Records . 1207.11.G Free Exercise of Rights. 1207.11.H Health Care Services . 1207.12Member Advisory Committee . 1217.13Advanced Directives. 1217.14Cultural Competency . 1217.15Member Services . 1227.15.A Member Services Call Center . 1227.15.B Call Center Components . 1227.15.C Specific Standards . 1227.16Outreach to Medicaid Expansion Population . 1237.16.A Outreach to Homeless Population . 1237.16.B Services for Justice-Involved Members . 1237.17Member Education Program . 124Medallion 4.0 Managed Care Contract SFY21v36

8.Benefit Service Requirements and Limits . .2.S8.2.T8.2.U8.2.V8.2.WGeneral Program Information . 124Cost-Sharing . 124Coverage of Authorized Services . 124Modification in Scope of Covered Services During a Contract Year . 125Utilization Management/Authorization Program Description . 125Medical Necessity. 128Coordination of Care Provisions . 129Transition of Care Provisions . 133Complex Care Management Programs Minimum Requirements. 134Required Reform Initiatives . 135Moral or Religious Objections . 135Notification to the Department of Sentinel Events . 135Out-of-Network Services . 135Mental Health or Substance Use Disorder Out-of-Network Benefits . 136Out-of-State Services . 137Patient Utilization Management & Safety (PUMS) Program for Members . 137Electronic Visit Verification (EVV) System . 139Court-Ordered Services . 140Second Opinions . 140Mental Health Parity. 141At-Risk Populations. 142Covered Services .

Managed Care Services Agreement CONTRACT TO PROVIDE MANAGED CARE SERVICES FOR THE MEDICAID and FAMILY ACCESS TO MEDICAL INSURANCE SECURITY (FAMIS) PROGRAMS JULY 1, 2020 - JUNE 30, 2021 . Medallion 4.0 Managed Care Contract SFY21v3 2 CONTENTS

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