- 1 - ) ADDENDUM A Regulatory Compliance Addendum Governing Illinois Medicaid Services This Regulatory Compliance Addendum Governing Illinois Medicaid Services (the “Illinois Medicaid Addendum”) shall govern the provision of Covered Services to Members who are eligible and covered under, as well as the provision of any administrative or health-benefit management services/functions that relate to, as applicable: (1) the State of Illinois Contract Between the Department of Healthcare and Family Services and a managed care organization (“MCO” or “Company”), which governs the program known as the Illinois Integrated Care Program a/k/a the ICP (the “ICP Contract”); and/or (2) the State of Illinois Contract Between the Department of Healthcare and Family Services and a managed care organization (“MCO” or “Company”), which governs the program known as the Illinois Family Health Plan Population–Affordable Care Act Adult program a/k/a FHP-ACA program (the “FHP-ACA Contract”). The State requires that specific terms and conditions be incorporated into the Agreement. As such, this Illinois Medicaid Addendum is incorporated by reference into the Agreement between Company (or its Affiliate, as the case may be) and the provider, vendor, contractor, or other entity executing this Agreement (as identified on the first page thereof), and such provider, vendor, contractor, or other entity must comply with the requirements set forth herein. Note that this Illinois Medicaid Addendum contains some, but not all, of the terms and requirements with which you must comply. Other terms and requirements with which you must comply are set forth in the Agreement and in the policies, procedures, and provider manual of Company (or its Affiliate, as the case may be). This Illinois Medicaid Addendum and the Agreement may be revised as directed by the State. For purposes of this Illinois Medicaid Addendum, the individuals who are enrolled with Company under the State Contracts will be referred to as the “Enrollees.” All capitalized terms not defined in this Illinois Medicaid Addendum shall have the respective meanings that are ascribed to them in the Agreement. If there is any conflict between the terms of this Illinois Medicaid Addendum and any of the other terms of this Agreement, including any attachments, schedules, exhibits, and/or addenda made part of this Agreement, the terms of this Illinois Medicaid Addendum will govern and control with respect to the provision of Covered Services to Members who are eligible and covered under the State Contracts and with respect to the provision of any administrative or health-benefit management services/functions that relate to those Covered Services or to the State Contracts. Except as provided herein, all other provisions of the Agreement not inconsistent with this Illinois Medicaid Addendum shall remain in full force and effect, and to the extent possible under applicable law, the terms of this Illinois Medicaid Addendum shall be construed to be supplementary to, and not in conflict with, the terms and conditions of the Agreement. The provider, vendor, contractor, or other entity identified on the first page of the Agreement acknowledges and agrees that all provisions of this Illinois Medicaid Addendum shall apply equally to its/their employees, independent contractors, subcontractors, downstream entities, or related entities that provide Covered Services to Members who are eligible and covered under the State Contracts, or that provide administrative or health-benefit management services/functions relating to those Covered Services or to the State Contracts, and it/they represent and warrant that it/they shall take all steps necessary to cause such employees, independent contractors, subcontractors, downstream entities, or related entities to comply with this Illinois Medicaid Addendum and all applicable laws and regulations.
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ADDENDUM A
Regulatory Compliance Addendum Governing Illinois Medicaid Services
This Regulatory Compliance Addendum Governing Illinois Medicaid Services (the “Illinois Medicaid Addendum”) shall govern the provision of Covered Services to Members who are eligible and covered under, as well as the provision of any administrative or health-benefit management services/functions that relate to, as applicable:
(1) the State of Illinois Contract Between the Department of Healthcare and Family Services and a managed
care organization (“MCO” or “Company”), which governs the program known as the Illinois Integrated Care Program a/k/a the ICP (the “ICP Contract”); and/or
(2) the State of Illinois Contract Between the Department of Healthcare and Family Services and a managed care organization (“MCO” or “Company”), which governs the program known as the Illinois Family Health Plan Population–Affordable Care Act Adult program a/k/a FHP-ACA program (the “FHP-ACA Contract”).
The State requires that specific terms and conditions be incorporated into the Agreement. As such, this Illinois Medicaid Addendum is incorporated by reference into the Agreement between Company (or its Affiliate, as the case may be) and the provider, vendor, contractor, or other entity executing this Agreement (as identified on the first page thereof), and such provider, vendor, contractor, or other entity must comply with the requirements set forth herein. Note that this Illinois Medicaid Addendum contains some, but not all, of the terms and requirements with which you must comply. Other terms and requirements with which you must comply are set forth in the Agreement and in the policies, procedures, and provider manual of Company (or its Affiliate, as the case may be). This Illinois Medicaid Addendum and the Agreement may be revised as directed by the State.
For purposes of this Illinois Medicaid Addendum, the individuals who are enrolled with Company under the State Contracts will be referred to as the “Enrollees.” All capitalized terms not defined in this Illinois Medicaid Addendum shall have the respective meanings that are ascribed to them in the Agreement.
If there is any conflict between the terms of this Illinois Medicaid Addendum and any of the other terms of this Agreement, including any attachments, schedules, exhibits, and/or addenda made part of this Agreement, the terms of this Illinois Medicaid Addendum will govern and control with respect to the provision of Covered Services to Members who are eligible and covered under the State Contracts and with respect to the provision of any administrative or health-benefit management services/functions that relate to those Covered Services or to the State Contracts. Except as provided herein, all other provisions of the Agreement not inconsistent with this Illinois Medicaid Addendum shall remain in full force and effect, and to the extent possible under applicable law, the terms of this Illinois Medicaid Addendum shall be construed to be supplementary to, and not in conflict with, the terms and conditions of the Agreement.
The provider, vendor, contractor, or other entity identified on the first page of the Agreement acknowledges and agrees that all provisions of this Illinois Medicaid Addendum shall apply equally to its/their employees, independent contractors, subcontractors, downstream entities, or related entities that provide Covered Services to Members who are eligible and covered under the State Contracts, or that provide administrative or health-benefit management services/functions relating to those Covered Services or to the State Contracts, and it/they represent and warrant that it/they shall take all steps necessary to cause such employees, independent contractors, subcontractors, downstream entities, or related entities to comply with this Illinois Medicaid Addendum and all applicable laws and regulations.
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CONTRACTUAL AND STATUTORY/REGULATORY REQUIREMENTS
A. Definitions
The following additional definitions shall apply with respect to the requirements set forth in this Illinois Medicaid Addendum:
a. “Authorized Persons” – Collectively means HFS, HFS’s Office of Inspector General (“HFS OIG”), the Medicaid Fraud Control Unit of the Illinois State Police, the Illinois Auditor General, the United States Department of Health and Human Services and the Centers for Medicare and Medicaid Services (“CMS”), and any other State or federal agencies with monitoring authority related to Medicaid. [ICP Contract § 1.19; FHP-ACA Contract § 1.20]
b. “Provider” – Means any individual or entity that is enrolled with the State to provide Covered Services to Enrollees and that is associated with Company pursuant to a written contract or agreement for the purpose of providing health care services under the State Contracts. [ICP Contract §§ 1.16, 1.118; FHP-ACA Contract §§ 1.16, 1.17, 1.122]
c. “Subcontractor” – Means any individual or entity, other than a Provider, with which Company has entered into a written agreement for the purpose of delegating responsibilities applicable to Company under the State Contracts. [ICP Contract § 1.144; FHP-ACA Contract § 1.148]
B. Requirements Applicable to State Contracts and Covered Services
1. Practice Coverage and Hours; Enrollee Appointments. Provider agrees to provide Covered Services to Enrollees as set forth in the Agreement, including without limitation the following when such Covered Services are specified in the Agreement:
a. Primary care providers (PCPs) and specialty Providers shall provide coverage for their
respective practices twenty-four (24) hours a day, seven (7) days a week and have a published after-hours telephone number (after-hours voicemail alone is not acceptable). [ICP Contract § 5.6.4; FHP-ACA Contract § 5.7.4]
b. Provider shall offer to Enrollees hours of operation that are no less than the hours of
operation offered to persons who are not Enrollees. [ICP Contract § 5.6.3; FHP-ACA Contract § 5.7.3]
c. Provider shall ensure that time-specific appointments for routine, preventive care to an Enrollee are available within five (5) weeks from the date of request for such care, and within two (2) weeks from the date of request for infants under age six (6) months. If an Enrollee has more serious problems that are not deemed emergency medical conditions, Provider shall triage that Enrollee and, if necessary or appropriate, immediately refer that Enrollee for urgent medically necessary care or provide that Enrollee with an appointment within one (1) business day of the request. If an Enrollee has a problem or complaint that is not deemed serious, Provider shall see that Enrollee within three (3) weeks from the date of request for such care. If Enrollee seeks an initial prenatal visit without expressed problems, the Provider shall see that Enrollee within two (2) weeks after a request if the Enrollee is in her first trimester, within one (1) week if the Enrollee is in her second trimester, and within three (3) days if the Enrollee is in her third trimester. [ICP Contract § 5.6.3; FHP-ACA Contract § 5.7.3]
2. Payments; Hold Harmless of Enrollees/State.
a. Provider/Subcontractor acknowledges and agrees that Company shall not pay a Provider/Subcontractor for any provider-preventable condition. Provider/Subcontractor shall report all provider-preventable conditions associated with claims for payment or Enrollee treatments for which payment would otherwise be made. [FHP-ACA Contract § 5.25.8]
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b. Provider/Subcontractor acknowledges and agrees that Company is prohibited by applicable federal law from making payments to financial institutions located outside of the United States for items or services provided under a Medicaid state plan or waiver.
c. Except as permitted or required by HFS in 89 Ill. Adm. Code 125, in HFS’s fee-for-
service copayment policy in effect at the time Covered Services are provided, and/or in the State Contracts, neither Company nor Provider/Subcontractor may seek or obtain funding through fees or charges to any Enrollee receiving Covered Services under the State Contracts. Provider/Subcontractor furthermore acknowledges and agrees that imposing charges in excess of those permitted under the State Contracts is a violation of Section 1128B(d) of the Social Security Act and subjects the party imposing such charges to criminal penalties. [ICP Contract § 5.30; FHP-ACA Contract § 5.30]
d. Provider/Subcontractor agrees that in no event, including but not limited to the
nonpayment by Company of amounts due to Provider/Subcontractor under the Agreement, the insolvency of Company, or any breach of the Agreement by Company, shall Provider/Subcontractor or its assignees or subcontractors have a right to seek any type of payment from, bill, charge, collect a deposit from, or have any recourse against the Enrollee or persons acting on the Enrollee’s behalf (other than Company) for services provided pursuant to the Agreement except for the payment of applicable copayments or deductibles for services covered by Company or fees for services not covered by Company. The requirements of this provision shall survive any termination of the Agreement for services rendered prior to such termination, regardless of the cause of such termination. Company’s Enrollees and all persons acting on the Enrollees’ behalf (other than Company) shall be third-party beneficiaries of this provision. This provision supersedes any oral or written agreement now existing or hereafter entered into between Provider/Subcontractor and the Enrollee or persons acting on the Enrollee’s behalf (other than Company). [215 ILCS 125/2-8(a)]
e. Any dispute between Company and Provider/Subcontractor shall be solely between those
parties, and Company and Provider/Subcontractor shall each hold harmless the State and its agencies, officers, employees, agents, and volunteers from and against such dispute and any and all liabilities, demands, claims, suits, losses, damages, causes of action, fines, or judgments, including costs, attorneys’ and witnesses’ fees, and expenses incident thereto, regardless of the reason. [ICP Contract §§ 7.13, 9.1.8, 9.1.28; FHP-ACA Contract §§ 7.13, 9.1.8, 9.1.28]
3. Standards of Care. In addition to complying with other applicable standards of care,
Provider/Subcontractor shall:
a. Timely identify any Enrollees with high-risk pregnancies and arrange for a maternal fetal medicine specialist or a transfer to Level III perinatal facilities in accordance with ACOG guidelines and the Illinois Perinatal Act requirements for referral and/or transfer of high-risk women. [ICP Contract, Attachment XXI ¶ 3.c.i.D; FHP-ACA Contract, Attachment XXI ¶ 3.c.i.D]
b. Cooperate and communicate with other service providers who serve Enrollees, including
without limitation Special Supplemental Nutrition Programs for Women, Infants, and Children (commonly referred to as “WIC” programs); Head Start programs; Early Intervention programs; and school systems. Such cooperation may include performing annual physical examinations for schools and the sharing of information (with the consent of the Enrollee). [ICP Contract, Attachment XXI ¶ 3.e.i.; FHP-ACA Contract, Attachment XXI ¶ 3.e.i.]
4. Cultural Competence; Prohibition on Discrimination. In addition to complying with other
applicable standards:
a. Provider/Subcontractor shall cooperate in the implementation of, and comply with all requirements set forth in, Company’s Cultural Competence Plan, which shall include implementation of the NCQA Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards). Provider/Subcontractor acknowledges and agrees that all Covered Services shall be provided in a culturally
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competent manner by ensuring the cultural competence of all Provider/Subcontractor staff, from clerical to executive management. Furthermore, Subcontractors shall complete Company’s initial and annual cultural- competence training. [ICP Contract §§ 2.7, 2.7.3, 2.7.4; FHP-ACA Contract §§ 2.7, 2.7.3, 2.7.4]
b. Provider/Subcontractor shall abide by all federal and State laws, regulations, and orders
that prohibit discrimination because of race, color, religion, sex, national origin, ancestry, age, physical or mental disability, including, but not limited to, the Federal Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, the Federal Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972 (regarding education programs and activities), the Age Discrimination Act of 1975, the Illinois Human Rights Act, and Executive Orders 11246 and 11375. Provider/Subcontractor furthermore agrees to take affirmative action to ensure that no unlawful discrimination is committed in any manner including, but not limited to, the delivery of services under this Agreement. Provider/Subcontractor will furthermore not discriminate against Enrollees or prospective or potential Enrollees on the basis of health status, need for health services, or payment source. All Provider/Subcontractor locations where Enrollees receive Covered Services shall comply with the Americans with Disabilities Act of 1990. [77 Ill. Admin. Code § 240.50(d)(4); ICP Contract §§ 2.8, 5.6.2, 9.1.22; FHP-ACA Contract §§ 2.8, 5.7.2, 9.1.22]
5. Anti-Gag Clause; Prohibition on Retaliation. Provider/Subcontractor shall not be prohibited or
otherwise restricted or discouraged from, and shall not prohibit or otherwise restrict or discourage its downstream providers or subcontractors from, taking any of the following actions so long as those actions are within the lawful scope of the acting party’s practice: (a) advocating for medically appropriate health care services for Enrollees, which may include without limitation appealing denials and protesting decisions, policies, and practices; (b) advising an Enrollee about the health status of that Enrollee or medical care or treatment for that Enrollee’s condition or disease regardless of whether benefits for such care or treatment are provided under the Agreement and/or the State Contracts; and/or (c) discussing with Enrollees, prospective Enrollees, or the public any health care services, health care providers, utilization review policies, quality assurance policies, or terms and conditions of plans and plan policy. Furthermore, Company shall not retaliate against Provider/Subcontractor, and Provider/Subcontractor shall not retaliate against its downstream providers or subcontractors, for any of the foregoing actions. Notwithstanding the foregoing, nothing in this provision shall be construed to prohibit: (a) Company or Provider/Subcontractor from making a determination not to pay for a particular health care service, from enforcing reasonable peer review or utilization review protocols, or from determining whether a physician or other health care provider has complied with those protocols; and/or (b) a Provider that is a hospital from taking disciplinary actions against a physician as authorized by law. [215 ILCS 134/30(a); 215 ILCS 134/35(a)–(d); ICP Contract § 5.32; FHP-ACA Contract § 5.32]
6. Grievances and Appeals. Provider/Subcontractor shall comply with Company’s grievance and
appeal processes referenced in the Agreement, and Company shall notify Provider/Subcontractor within fifteen (15) days following any substantive change to such procedures. [ICP Contract § 5.28.6; FHP-ACA Contract § 5.28.6]
7. Data and Reporting.
a. Provider/Subcontractor shall submit all data, reports, and clinical information required by Company under the State Contracts in such manner and format, and pursuant to such timeframes, as requested by Company and/or HFS. Provider/Subcontractor shall ensure that all data and reports that it submits to Company are accurate and complete, and Provider/Subcontractor furthermore acknowledges and agrees that all such data and reports shall be available to HFS and, upon request, to federal CMS. [ICP Contract § 5.24; FHP-ACA Contract § 5.24]
b. If Provider/Subcontractor provides Covered Services to Enrollees under a Illinois
Department of Human Services (“DHS”) Home and Community-Based Services (“HCBS”) Waiver, under the Medicaid Clinic Option, or under the Medicaid Rehabilitation Option, or provides subacute alcoholism and substance-abuse treatment services pursuant to 89 Ill. Admin. Code §§ 148.340–148.390 and 77 Ill. Admin. Code Part 2090, such Provider/Subcontractor shall enter any data regarding Enrollees that is required under State rules, or under a contract between the Provider/Subcontractor and DHS, into any subsystem maintained by DHS, including, but not limited to, DHS’s Automated Reporting and Tracking System (DARTS). [FHP-ACA Contract § 5.28.1.3]
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8. Delegation. If Company delegates to Provider/Subcontractor any activities or obligations under the State Contracts:
a. Company shall remain ultimately responsible for the performance of those
responsibilities and nothing in the Agreement shall be construed to terminate Company’s legal responsibility to DHS to assure that all activities under the State Contracts are carried out. [ICP Contract §§ 5.28.2, 5.28.3; FHP-ACA Contract §§ 5.28.2, 5.28.3]
b. Provider/Subcontractor acknowledges and agrees that Company’s delegated oversight
committee will oversee Provider/Subcontractor’s activities and performance under the Agreement to ensure compliance with all applicable contractual and statutory requirements, including without limitation the Illinois Human Rights Act, the U.S. Civil Rights Act, and Section 504 of the federal Rehabilitation Act. Company’s oversight of Provider/Subcontractor will include, without limitation: pre-delegation audits; quarterly delegation oversight reviews of delegate performance; monthly joint-operation meetings; annual audits of Provider/Subcontractor; regular monitoring of Enrollee complaints with respect to Provider/Subcontractor; and documentation of issues and development of a corrective action plan, as warranted, to improve performance. [ICP Contract § 2.7.4; FHP-ACA Contract § 2.7.4]
c. To the extent that such delegated activities are credentialing or recredentialing activities
or obligations under the State Contracts, Provider/Subcontractor shall maintain a formal credentialing program and shall conduct all such activities or obligations in compliance with Company, National Committee for Quality Assurance (NCQA), and State standards. Company shall monitor such credentialing/recredentialing delegated activities and shall review Provider/Subcontractor’s credentialing files no less than annually as part of the annual audit. [ICP Contract § 5.7.4, Attachment XI ¶ 7.e.; FHP- ACA Contract § 5.8.4, Attachment XI ¶ 7.e.]
9. Quality Assurance. With respect to Company’s quality-assurance obligations under the State
Contracts:
a. Provider/Subcontractor shall participate in and cooperate with Company’s quality- assurance program (QAP), shall cooperate with Company with respect to Company’s QAP obligations under the State Contracts, and shall cooperate with Company’s quality improvement committee. Provider/Subcontractor shall furthermore allow Company to access Provider/Subcontractor’s Enrollee medical records to permit effective quality review, and such access shall include the right of Company to make and/or obtain a copy (in either electronic or hardcopy form) of such records. [ICP Contract, Attachment XI ¶ 6.b.; FHP-ACA Contract, Attachment XI ¶ 6.b.]
b. Provider/Subcontractor shall provide, arrange for, or participate in the quality-assurance
programs mandated by the Illinois Health Maintenance Organization Act, unless the Illinois Department of Public Health has certified that such programs will be fully implemented without any participation or action from Provider/Subcontractor. [215 ILCS 125/2-8(a); 50 Ill. Admin. Code § 5241.50(a)(4)]
c. Provider/Subcontractor acknowledges and agrees that Company shall perform quality-
assurance evaluations of Provider/Subcontractor’s practices, which shall include monitoring of Enrollee accessibility to ensure linguistic and physical accessibility. [ICP Contract § 2.7.5; FHP-ACA Contract § 2.7.5]
d. Provider/Subcontractor shall cooperate and comply with all remedial or corrective actions
that Company implements with respect to Provider/Subcontractor and/or its services under the Agreement, upon Company’s determination that Provider/Subcontractor has furnished inappropriate or substandard services or has failed to furnish services that should have been furnished. [ICP Contract, Attachment XI ¶ 3.e.; FHP-ACA Contract, Attachment XI ¶ 3.e.]
e. If Company delegates to Provider/Subcontractor any quality-assurance activities or
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obligations that Company has under the State Contracts:
(i) Company and Provider/Subcontractor shall agree in writing upon the delegated activities, the accountability of Provider/Subcontractor for those activities, and the frequency of Provider/Subcontractor’s reporting to Company related to those activities. [ICP Contract, Attachment XI ¶ 7.a.; FHP-ACA Contract, Attachment XI ¶ 7.a.]
(ii) Company and Provider/Subcontractor shall agree in writing upon the standards
and procedures for monitoring and evaluating the implementation of the delegated functions and for verifying the actual quality of care being provided. [ICP Contract, Attachment XI ¶ 7.b.; FHP- ACA Contract, Attachment XI ¶ 7.b.]
(iii) All such delegated activities shall conform to the requirements set forth in the
State Contracts. [ICP Contract, Attachment XI ¶ 7.c.; FHP-ACA Contract, Attachment XI ¶ 7.c.]
(iv) Provider/Subcontractor acknowledges and agrees that Company shall engage in continuous and ongoing evaluation and oversight of such delegated activities, including approval of quality-improvement plans and regular specified reports, as well as a formal review of such activities. Company’s oversight of Provider/Subcontractor’s performance of these delegated activities must include no less than an annual audit, analyses of required reports and encounter data, a review of Enrollee complaints, grievances, Provider complaints, and quality of care concerns raised through encounter data, monitoring activities, or other venues. Outcomes of Company’s annual audit shall be submitted to HFS as part of Company’s QA/UR/PR Annual Report. [ICP Contract, Attachment XI ¶ 7.d.; FHP-ACA Contract, Attachment XI ¶ 7.d.]
(v) If Company or Provider/Subcontractor identifies areas requiring improvement,
Company or Provider/Subcontractor, as appropriate, shall take corrective action and implement a quality improvement initiative. If one or more deficiencies are identified, Provider/Subcontractor must develop and implement a corrective action plan, with protections put in place by Company to prevent such deficiencies from recurring. Evidence of ongoing monitoring of the delegated activities sufficient to assure corrective action shall be provided to HFS through quarterly or annual reporting. [ICP Contract, Attachment XI ¶ 7.f.; FHP-ACA Contract, Attachment XI ¶ 7.f.]
10. Pharmacy Benefits. In addition to the other requirements set forth herein that are applicable to
Covered Services, with respect to pharmacy-related Covered Services:
a. Provider/Subcontractor shall administer all pharmacy benefits in accordance with the provisions and requirements of the State Contracts and all applicable State and federal laws and regulations. [ICP Contract §§ 5.1.7, 5.16.6; FHP-ACA Contract §§ 5.2.5, 5.16.6]
b. Provider/Subcontractor shall cooperate with Company with respect to Company’s
obligations under the State Contracts to submit required pharmacy-related reports and data to applicable federal and State authorities. [ICP Contract, Attachment XIII; FHP-ACA Contract, Attachment XIII]
c. If Company delegates to Provider/Subcontractor any pharmacy-related activities or
obligations that Company has under the State Contracts, Provider/Subcontractor shall comply with all pharmacy-related provisions and requirements set forth in the State Contracts, including without limitation the following, as applicable:
(i) Company and Provider/Subcontractor shall submit a pharmacy formulary for
prior approval by the State initially and annually thereafter. [ICP Contract § 5.1.7; FHP-ACA Contract § 5.2.5]
(ii) Company and Provider/Subcontractor shall provide coverage of drugs in all
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classes of drugs for which HFS’s fee-for-service program provides coverage. [ICP Contract § 5.1.7.1; FHP-ACA Contract § 5.2.5.1]
(iii) Company and Provider/Subcontractor shall cover only drugs made by manufacturers that participate in the federal Medicaid drug rebate program, which applies to both prescription and over-the-counter drugs, but does not apply to non-drug items such as blood sugar test strips. HFS will provide a listing of manufacturers that participate in the federal Medicaid drug rebate program. [ICP Contract § 5.1.7.2; FHP-ACA Contract § 5.2.5.2]
(iv) Company and Provider/Subcontractor may determine their own utilization
controls, including without limitation step therapy and prior approval, unless otherwise prohibited under the State Contracts, to ensure appropriate utilization. Company and Provider/Subcontractor shall utilize HFS’s step-therapy and prior-authorization requirements for family-planning drugs and devices as set forth in the State Contracts. [ICP Contract § 5.1.7.3; FHP-ACA Contract § 5.2.5.3]
(v) Company and Provider/Subcontractor shall ensure that they require pharmacy,
medical, and hospital providers to identify 340B-purchased drugs on pharmacy, medical, and hospital claims following HFS billing guidelines applied in HFS’s fee-for-service program, and Company and Provider/Subcontractor shall furthermore ensure that its encounter claims to HFS identify these drugs. [ICP Contract § 5.1.7.4; FHP-ACA Contract § 5.2.5.4] For any outpatient drugs not identified in accordance with the previous sentence: (i) Company and Provider/Subcontractor shall collect information on the total number of units of each dosage form and strength and package size by National Drug Code of each covered outpatient drug dispensed to Enrollees, and (ii) Company and Provider/Subcontractor shall report to HFS quarterly, in a format and in the detail specified by HFS, information on the total number of units of each dosage form and strength and package size by National Drug Code of each such covered outpatient drug dispensed to Enrollees. [FHP-ACA Contract §§ 5.2.5.4.1, 5.2.5.4.2]
(vi) Company and Provider/Subcontractor shall establish and maintain a generic
drug Maximum Allowable Cost (MAC) dispute-resolution process, subject to approval by HFS. The MAC dispute-resolution process shall enable pharmacies to report pricing disputes to the Company and/or Provider/Subcontractor up to sixty (60) days from the claim date and Company and/or Provider/Subcontractor is required to resolve the pricing dispute within twenty-one (21) days by adjusting the reimbursement rate to represent the average acquisition cost of the drug, or by informing the pharmacy of alternative generic equivalent products that can be purchased at or below the Company’s existing MAC price. [ICP Contract § 5.1.7.5; FHP-ACA Contract § 5.2.5.5]
(vii) Company and Provider/Subcontractor shall develop and implement a system,
including policies and procedures, coverage criteria, and processes for their Drug Utilization Review (DUR) program. The DUR program shall include a prospective review process for all drugs prior to dispensing and all non-formulary drug requests, and a retrospective drug utilization review process to detect patterns in prescribing, dispensing, or administration of medication and to prevent inappropriate use or abuse. Company and Provider/Subcontractor are required to report prospective and retrospective DUR activities to HFS quarterly, and to assist in data collection and reporting to HFS of data necessary to complete the federal CMS DUR annual report. [ICP Contract § 5.1.7.6; FHP-ACA Contract § 5.2.5.6]
(viii) Company and Provider/Subcontractor shall comply with the pharmacy prior-
authorization provisions and requirements set forth in Section 5.16.6 of each of the State Contracts, which requires that Company and/or Provider/Subcontractor must authorize or deny a prior-authorization request for pharmacy services no later than twenty-four (24) hours after receipt of the request for authorization. [ICP Contract § 5.16.6; FHP-ACA Contract § 5.16.6]
(ix) Company and Provider/Subcontractor shall not permit or allow, whether by
contract, written policy, or procedure, any individual or entity to dispense a different drug in place
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of the drug or brand of drug ordered or prescribed without the express permission of the person ordering or prescribing the drug, except as provided under Section 3.14 of the Illinois Food, Drug and Cosmetic Act (codified at 410 ILCS 620/3.14). [215 ILCS 134/30(b)]
11. Children’s Mental Health Service Requirements. In addition to the other requirements set forth
herein that are applicable to Covered Services, with respect to any behavioral-health Covered Services that Provider/Subcontractor provides to Enrollees under the age of twenty one (21):
a. Provider/Subcontractor shall administer all such behavioral-health benefits in accordance
with the provisions and requirements of Attachment XXII of the FHP-ACA Contract and in accordance with all applicable State and federal laws and regulations. [FHP-ACA Contract, Attachment XXII]
b. If Provider is an inpatient psychiatric Provider, it shall administer a physical examination
to the Enrollee within twenty-four (24) hours after admission when that Enrollee requires admission to an appropriate inpatient institutional treatment setting. [FHP-ACA Contract, Attachment XXII, ¶ 4.c.iv.]
c. Provider shall comply with Company’s procedures with respect to discharge and
transitional planning related to an appropriate inpatient institutional treatment setting, and shall cooperate with Company in the education and training of the Enrollee’s family on how to use the “crisis safety plans” while the Enrollee is receiving inpatient institutional treatment. [FHP-ACA Contract, Attachment XXII, ¶ 4.c.v.5.]
d. If Provider/Subcontractor provides Mobile Crisis Response Services in connection with
the State Contracts:
(i) Provider/Subcontractor shall ensure that the staff providing those services hold the following credentials: (a) Mental Health Professional (MHP) with direct access to a Qualified Mental Health professional; (b) Qualified Mental Health Professional; or (c) Licensed Practitioner of the Healing Arts. [FHP-ACA Contract, Attachment XXII, ¶ 3.f.]
(ii) Provider/Subcontractor shall provide immediate crisis and stabilization services
when an Enrollee in crisis can be stabilized in the community. [FHP-ACA Contract, Attachment XXII, ¶ 4.a.i.]
(iii) Provider/Subcontractor shall establish a “crisis safety plan” for all Enrollees
presenting in behavioral-health crisis that is unique to the Enrollee and the circumstances leading to the crisis situation. [FHP-ACA Contract, Attachment XXII, ¶¶ 4.a.ii., 4.b.i.]
(iv) Provider/Subcontractor shall provide the Enrollee’s family with contact
information that may be used at any time, 24 hours a day, to contact Company in moments of crisis. [FHP-ACA Contract, Attachment XXII, ¶ 4.a.iv.]
(v) Provider/Subcontractor shall provide families of Enrollees with physical copies
of the “crisis safety plan” (a) prior to the completion of the crisis screening event for any Enrollee stabilized in the community, and (b) prior to discharge of the Enrollee from an inpatient psychiatric hospital for any Enrollee that is admitted to such a facility. [FHP-ACA Contract, Attachment XXII, ¶ 4.b.ii.]
(vi) Provider/Subcontractor shall educate and orient the Enrollee’s family to the
components of the “crisis safety plan” to ensure that the plan is reviewed with the family regularly, and to detail how the plan is updated as necessary. [FHP-ACA Contract, Attachment XXII, ¶ 4.b.iii.]
(vii) Provider/Subcontractor shall share the “crisis safety plan” with all necessary
medical professionals, including care coordinators, consistent with the authorizations established
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by consent or release. [FHP-ACA Contract, Attachment XXII, ¶ 4.b.iv.]
(viii) Provider/Subcontractor shall facilitate the Enrollee’s admission to an appropriate inpatient institutional treatment setting when the Enrollee in crisis cannot be stabilized in the community. [FHP-ACA Contract, Attachment XXII, ¶ 4.c.i.]
(ix) Provider/Subcontractor shall inform the Enrollee’s parents, guardian, caregivers,
or residential staff about all of the available service providers and pertinent policies needed to allow the involved parties to select an appropriate inpatient institutional treatment setting. [FHP- ACA Contract, Attachment XXII, ¶ 4.c.ii.]
12. Third Party Liability. Provider/Subcontractor acknowledges and agrees that Medicaid payment,
under the State Contracts or otherwise, is secondary to other sources of payment for Covered Services provided to Enrollees, and that Medicaid (and consequently Company, as a Medicaid MCO of the State) is the payer of last resort. Provider/Subcontractor furthermore acknowledges and agrees that when Company is aware of third-party sources of payment for Covered Services, Company is required to “cost avoid” (i.e., deny) the associated claim and to redirect Provider/Subcontractor to bill that third-party source of payment as the primary payor.
13. Cooperation with Company. Provider/Subcontractor shall cooperate with Company with respect
to Company’s obligations under the State Contract, including without limitation:
a. Company’s obligation to submit financial and expense-related reports/data to the State relating to the risk adjustment and Medical Loss Ratio (MLR) adjustment set forth in the State Contracts. [ICP Contract §§ 7.4, 7.11; FHP-ACA Contract §§ 7.4, 7.11]
b. Company’s obligation to investigate, pursue, and report on coordination-of-benefit and
third-party-liability resources and recoveries. [ICP Contract §§ 9.1.37, 9.1.38; FHP-ACA Contract §§ 9.1.36, 9.1.37]
c. Company’s obligation to provide a “medical home,” as that term is used in the State
Contracts, for its Enrollees. [ICP Contract §§ 5.5.7, 5.9.2; FHP-ACA Contract §§ 5.6.7, 5.9.2]
d. Company’s obligation to encourage Provider/Subcontractor to support Enrollees in directing their own care and in development of the Enrollee’s care plan. [ICP Contract § 5.12.6; FHP-ACA Contract § 5.14.5; 5.14.8.1.3]
e. Company’s obligation to avoid unnecessary utilization of emergency services by
Enrollees and to promote care management through the Enrollees’ primary care providers (PCPs) or “medical home.” [ICP Contract § 5.17.1.5; FHP-ACA Contract § 5.17.1.5]
f. Company’s obligation to establish and maintain an HFS-approved peer-review program
to review the quality of care that Provider/Subcontractor provides to Enrollees. [ICP Contract § 5.19.5; FHP-ACA Contract § 5.19.5]
g. Company’s obligation to provide orientation, education, and training for
Provider/Subcontractor as set forth in the State Contracts, including without limitation (i) training on how to identify, recognize potential concerns related to, and report on suspected or alleged abuse, neglect, and exploitation being suffered by Enrollees, and (ii) education on the application of required clinical guidelines. [ICP Contract §§ 5.9, 5.20.1, 5.20.2, Attachment XI ¶ 9, Attachment XXI ¶ 3; FHP-ACA Contract §§ 5.9, 5.20.4, 5.20.5, Attachment XI ¶ 9, Attachment XXI ¶ 3]
h. Company’s obligation to participate in any State-required performance-improvement
projects. [ICP Contract § 7.16.5; FHP-ACA Contract § 7.16.5]
i. Company’s obligation to remit to Provider/Subcontractor, if applicable, any “hospital
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access payments” authorized under 305 ILCS 5/5A-12.2(s)–(t) and 305 ILCS 5/5A-12.5 (Public Act 98- 651, enacted June 14, 2014). [ICP Contract § 7.1.5; FHP-ACA Contract § 7.1.2]
j. Company’s obligation to respond to any letter of concern, written deficiency notice, or
request for a corrective action plan that Company receives from the State relating to Provider/Subcontractor or the services that are within the scope of the Agreement. [ICP Contract § 7.16.6.1; FHP-ACA Contract § 7.16.6.1]
k. Company’s obligations and responsibilities relating to the “HMO self-evaluation
structure” and associated activities set forth in 77 Ill. Admin. Code § 240.60. [77 Ill. Admin. Code § 240.50(d)(1)(C)]
14. Notice of Legal Action. If Provider/Subcontractor, its parent, or one of its affiliates becomes a
party to any litigation, investigation, or transaction that may reasonably be considered to have a material impact on Provider/Subcontractor’s ability to perform under the Agreement, Provider/Subcontractor shall immediately notify Company in writing. [ICP Contract § 9.1.24; FHP-ACA Contract § 9.1.24]
15. State Review of Agreement. Provider/Subcontractor acknowledges and agrees that Company may
be required to submit a copy of the Agreement to HFS for review, and that HFS reserves the right to require Company to amend the Agreement as reasonably necessary to conform to Company’s duties and obligations under the State Contracts. [ICP Contract § 5.28.10; FHP-ACA Contract § 5.28.10]
16. Termination of Agreement and Effect Thereof.
a. In the event the Agreement is terminated, such termination shall not constitute termination of any other agreement that Provider/Subcontractor has entered into with Company or an Affiliate of Company unless otherwise agreed to in writing by the parties. Furthermore, in the event this Illinois Medicaid Addendum is terminated, such termination shall not constitute termination of any other Product Addendum or Product Participation that Provider/Subcontractor has entered into with Company pursuant to the Agreement unless otherwise agreed to in writing by the Parties.
b. Notwithstanding anything in the Agreement to the contrary, if either Company or
Provider/Subcontractor seeks (i) to terminate the Agreement “with cause” (as that term is used and defined in the Agreement), the terminating party shall provide at least sixty (60) days’ written notice to the other party; or (ii) to terminate the Agreement “without cause” (as that term is used and defined in the Agreement), the terminating party shall provide at least ninety (90) days’ written notice to the other party. Furthermore, Provider/Subcontractor shall cooperate with Company with respect to Company’s obligation to provide timely notice to Enrollees of any termination that would curtail or eliminate services to such Enrollees, with such notice to be sent (i) at least sixty (60) days prior to that termination, or (ii) immediately, if Company receives less than sixty (60) days’ notice of that termination from Provider/Subcontractor. The notice to be sent to Enrollees shall include instructions regarding referrals that have previously been issued and appointments that may be pending. [50 Ill. Admin. Code § 5241.50(a)(5)– (6); 305 ILCS 5/5F-40(a)]
c. Notwithstanding anything in the Agreement to the contrary, Company shall retain the
right to terminate the Agreement, or impose other sanctions, if the performance of Provider/Subcontractor is inadequate. Company shall monitor the performance of Provider/Subcontractor on an ongoing basis, shall subject Provider/Subcontractor to formal review on no less than a triennial basis, and to the extent deficiencies or areas for improvement are identified during an informal or formal review, shall require Provider/Subcontractor to take appropriate corrective action. Furthermore, Company shall promptly terminate the Agreement if Provider/Subcontractor is or becomes terminated, barred, or suspended, or has voluntarily withdrawn as a result of a settlement agreement, under either Section 1128 or Section 1128A of the Social Security Act, from participating in any program under federal law including any program under Titles XVIII, XIX, XX or XXI of the Social Security Act or are otherwise excluded from participation in the HFS Medical Program. [ICP Contract §§ 5.28.7, 5.28.9; FHP-ACA Contract §§ 5.28.7, 5.28.9]
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17. Maintenance, Access to, and Confidentiality of Records.
a. Provider/Subcontractor shall maintain books and records relating to the performance of the State Contracts and the Agreement and necessary to support amounts charged under the State Contracts and the Agreement. Books and records, including information stored in databases or other computer systems, shall be maintained by Provider/Subcontractor for a period of three (3) years from the later of the date of final payment under the Agreement or completion of the Agreement, or such longer time as may be required by federal law or regulation. Books and records required to be maintained under this provision shall be accessible for review or audit by representatives of Company or any Authorized Persons (along with the Executive Inspector General and the Chief Procurement Officer) upon reasonable notice and during normal business hours. Such access shall include the right to make and/or obtain a copy (in either electronic or hardcopy form) of such books and records. Provider/Subcontractor shall cooperate fully with any such audit and with any investigation conducted by any of these entities. Failure to maintain the books and records required by this provision shall establish a presumption in favor of the State for the recovery of any funds paid by the State under the State Contracts for which adequate books and records are not available to support the purported disbursement. Provider/Subcontractor shall not impose a charge for audit or examination of Provider/Subcontractor’s books and records. [ICP Contract § 9.1.2; FHP-ACA Contract § 9.1.2]
b. Provider/Subcontractor may have or gain access to confidential data or information
owned or maintained by the State or Company in the course of carrying out Provider/Subcontractor’s responsibilities under the Agreement and/or the State Contracts. Provider/Subcontractor shall presume all information received from the State or Company, or to which it gains access pursuant to the Agreement and/or the State Contracts, is confidential. No confidential data collected, maintained, or used in the course of performance of the Agreement and/or the State Contracts shall be disseminated except as authorized by law and with the written consent of the State and/or Company, as applicable, either during the term of the State Contracts or thereafter, unless otherwise expressly provided in the State Contracts. Provider/Subcontractor must return any and all data collected, maintained, created, or used in the course of the performance of the Agreement and/or the State Contracts, in whatever form it is maintained, promptly at the earlier of the termination of the Agreement or the termination of the State Contracts, or earlier at the request of the State, or notify the State and/or Company, as applicable, in writing of its destruction. The foregoing obligations shall not apply to confidential data or information that is: (i) lawfully in Provider/Subcontractor’s possession prior to its acquisition from the State and/or Company; (ii) received in good faith from a third-party not subject to any confidentiality obligation to the State and/or Company; (iii) now is or later becomes publicly known through no breach of confidentiality obligation by Provider/Subcontractor; or (iv) is independently developed by Provider/Subcontractor without the use or benefit of the confidential information of the State and/or Company. [ICP Contract § 9.1.6; FHP-ACA Contract § 9.1.6]
c. Provider/Subcontractor shall ensure that all information, records, data, and data elements
pertaining to applicants for and recipients of public assistance, or to providers, facilities, and associations, shall be protected from unauthorized disclosure by Provider/Subcontractor and Provider/Subcontractor’s employees, by Provider/Subcontractor’s corporate affiliates and their employees, and by Provider/Subcontractor’s subcontractors and their employees, pursuant to 305 ILCS 5/11-9, 11-10, and 11- 12; 42 U.S.C. § 654(26); 42 C.F.R. Part 431, Subpart F; and 45 C.F.R. Part 160 and 45 C.F.R. Part 164, Subparts A and E. To the extent that Provider/Subcontractor, in the course of performing under the terms of the Agreement, serves as a business associate of Company and/or HFS, as “business associate” is defined in the HIPAA Privacy Rule (45 C.F.R. § 160.103), Provider/Subcontractor shall assist Company and/or HFS in responding to the client as provided in the HIPAA Privacy Rule, and shall maintain for a period of six (6) years any records relevant to an individual’s eligibility for services under the HFS Medical Program. [ICP Contract § 9.1.21; FHP-ACA Contract § 9.1.21]
18. Provider/Subcontractor, to which Company provides Enrollee PHI that Company has received from HFS or created or received by Company on behalf of HFS, agrees to the same restrictions and conditions that apply under the terms of the State Contracts to Company with respect to
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such information. [ICP Contract, Attachment VI § C.5; FHP-ACA Contract, Attachment VI § C.5] Medical Records. With respect to Enrollee medical records:
a. In addition to the requirements set forth in the Agreement, Provider/Subcontractor shall maintain Enrollee medical records in a timely, legible, accurate, current, complete, and organized manner, with appropriate dates and identification and initialing/signature of the Provider/Subcontractor, to facilitate retrieval and compilation of records, to ensure Enrollee continuity of care, and to permit effective and confidential patient care and quality review. For each encounter or episode of care that Provider/Subcontractor has with an Enrollee, Provider/Subcontractor shall place the following information into the Enrollee’s medical records: (1) the reason for the encounter; (2) evidence of the Provider/Subcontractor’s assessment of the Enrollee’s health problems; (3) current diagnosis of the Enrollee, including the results of any diagnostic tests; (4) the plan of treatment, including any therapies and health education; (5) any medical history relevant to the current episode of care; and (6) confirmation that all outcomes of ancillary reports, such as laboratory tests and x-rays, have been reviewed by the individual or entity who ordered the reports and that follow-up actions have been taken regarding report results that are deemed significant by the individual or entity who ordered those reports. [77 Ill. Admin. Code §§ 240.50(c)(1), 240.90(a)–(b); ICP Contract § 5.23.3; FHP-ACA Contract § 5.23.3]
b. Provider/Subcontractor shall ensure that Enrollee medical records contain documented
efforts to obtain Enrollee consent when required by law. Provider/Subcontractor shall furthermore only release Enrollee medical records to Authorized Persons, or to any primary care provider (PCP), women’s health care provider (WHCP), or other Provider of Enrollee (subject to Enrollee’s consent when required by law), and shall only release original Enrollee medical records in accordance with federal or State law, court orders, subpoenas, or a valid records-release form executed by the Enrollee. Provider/Subcontractor shall protect the confidentiality and privacy of minors, and shall abide by all federal and State laws regarding the confidentiality and disclosure of medical records, mental health records, and any other information about Enrollees. Provider/Subcontractor shall produce Enrollee medical records to HFS upon request. [ICP Contract § 5.23.3; FHP-ACA Contract § 5.23.3]
c. If Provider/Subcontractor is an Enrollee’s primary care provider (PCP),
Provider/Subcontractor shall furthermore maintain a permanent medical record for that Enrollee to ensure continuity of care. The medical record for each Enrollee who has had a routine, scheduled appointment with his/her primary care provider (PCP) shall include the following information: (1) identification; (2) patient history; (3) known past surgical procedures; (4) known past and current diagnoses and problems; and (5) known allergies and untoward reactions to drugs. [77 Ill. Admin. Code § 240.90(c); ICP Contract § 5.23.3; FHP-ACA Contract § 5.23.3]
d. If Enrollee changes PCPs or “medical homes,” Provider/Subcontractor shall forward
Enrollee’s medical records or copies thereof to the new PCP or “medical home” promptly upon Enrollee’s transfer. [ICP Contract § 5.23.3; FHP-ACA Contract § 5.23.3]
e. Provider/Subcontractor shall only record diagnosis codes in Enrollee’s medical records at
the time of creation of that medical record, and shall not retroactively adjust any such diagnosis codes except to correct errors. [ICP Contract § 7.4.1; FHP-ACA Contract § 7.4.1]
19. Use of Hospitalists. Neither Company nor Provider/Subcontractor shall require or otherwise
mandate, whether by contract, written policy, or procedure, any Enrollee to substitute his or her participating primary care provider (PCP) during inpatient hospitalization, such as with a hospitalist physician, without the agreement of that Enrollee’s participating primary care provider (PCP). Company and Provider/Subcontractor (if applicable) shall inform Enrollees of any policies, recommendations, or guidelines concerning the substitution of the Enrollee’s primary care provider (PCP) when hospitalization is necessary in the manner set forth in 215 ILCS 5/15(d)–(e). [215 ILCS 134/30(c)] Provider Enrollment, Credentialing, Licensure, and Privileges.
a. Provider/Subcontractor shall be enrolled as a provider in the HFS Medical Program (as
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defined below), if such enrollment is required by HFS’s rules or policy in order to submit claims for reimbursement or otherwise participate in the HFS Medical Program. Provider/Subcontractor shall not, in turn, contract or subcontract with an individual or entity that has voluntarily withdrawn from the HFS Medical Program as the result of a settlement agreement. For purposes of this provision, the term “HFS Medical Program” means the (i) Illinois Medical Assistance Program administered under Article V of the Illinois Public Aid Code (305 ILCS 5/5-1 et seq.) or its successor program, and Titles XIX (42 U.S.C. § 1396 et seq.) and XXI (42 U.S.C. § 1397aa et seq.) of the Social Security Act, and Section 12-4.35 of the Illinois Public Aid Code (305 ILCS 5/12-4.35); and (ii) the State Children’s Health Insurance Program administered under 215 ILCS 106 and Title XXI of the Social Security Act (42 U.S.C. § 1397aa et seq.). [ICP Contract §§ 1.71, 5.28.4; FHP-ACA Contract §§ 1.75, 5.28.4]
b. Provider shall comply with all credentialing and recredentialing policies and procedures
that Company implements to verify Provider’s credentials, including without limitation by completing a credentialing application in accordance with applicable policies and procedures. Furthermore, Provider shall comply with all applicable credentialing/recredentialing standards and requirements set forth in the State Contracts and in applicable federal and State laws, regulations, and written policies. [ICP Contract § 5.7.1, Attachment XI ¶ 8; FHP-ACA Contract § 5.8.1, Attachment XI ¶ 8]
c. If Provider/Subcontractor operates a laboratory testing site that provides services to
Enrollees, (i) that site shall possess a valid Clinical Laboratory Improvement Amendment (CLIA) certificate and comply with the CLIA regulations found at 42 C.F.R. Part 493, and (ii) Provider/Subcontractor shall report lab values to Company directly. [ICP Contract §§ 5.19.2, 5.28.9.4; FHP-ACA Contract §§ 5.19.2, 5.28.9.4]
d. If Provider is a physician, such physician Provider shall have and maintain admitting
privileges and, as appropriate, delivery privileges at a hospital that is also a participating Provider with Company; or, in lieu of these admitting and/or delivery privileges, such physician Provider shall have a written referral agreement with a separate physician who is a participating Provider with Company and who has such privileges at a hospital that is also a participating Provider with Company. Such physician Provider shall coordinate care with the referring physician and shall ensure that Enrollee medical records are appropriately transferred; the physicians’ written referral agreement shall contain appropriate provisions that document and require such coordination of care and transfer of medical records. [ICP Contract § 5.28.1.2; FHP-ACA Contract § 5.28.1.2]
e. If Provider/Subcontractor provides long-term care and HCBS services under the
Agreement, Provider/Subcontractor shall be approved and authorized by the State to provide such Covered Services, and shall only provide to Enrollees those particular Covered Services for which they are approved and authorized. [FHP-ACA Contract § 5.8.5]
20. Disclosure of Ownership and Control; Prohibited Relationships; Background Checks.
a. Consistent with federal disclosure requirements described in 42 C.F.R. § 455.100 through 42 C.F.R. § 455.106 and 42 C.F.R. § 438.610, and to ensure that Company does not make a payment to an individual or entity that has been criminally convicted of a felony, is debarred, suspended, or otherwise excluded from participating in federal health care programs, or is 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, Provider/Subcontractor shall disclose to Company: any required ownership and control, relationship, and financial interest information; any changes to ownership and control, relationship, and financial interest information; and information on any criminal convictions regarding Provider/Subcontractor and any owner(s) and managing employee(s) at the time the Agreement is executed and annually thereafter, and any time there are changes to such information. [ICP Contract § 9.2.34; FHP- ACA Contract § 9.2.34]
b. No Provider/Subcontractor, no individual who has a direct or indirect ownership or controlling interest of 5% or more of that Provider/Subcontractor, and no officer, director, agent, or managing employee (i.e., general manager, business manager, administrator, director, or like individual
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who exercises operational or managerial control over that Provider/Subcontractor or who directly or indirectly conducts the day-to-day operation of that Provider/Subcontractor) shall be an entity or individual: (1) who has been convicted of any offense under Section 1128(a) of the Social Security Act (42 U.S.C. § 1320a-7(a)) or of any offense related to fraud or obstruction of an investigation or a controlled substance described in Section 1128(b)(1)–(3) of the Social Security Act (42 U.S.C. § 1320a-7(b)(1)–(3)); (2) against whom a civil monetary penalty has been assessed under Section 1128A or 1129 of the Social Security Act (42 U.S.C. §1320a-7a; 42 U.S.C. §1320a-8); or (3) who has been excluded from participation in a program under Title XVII, 1902(a)(39) and (41) of the Social Security Act, Section 4724 of the Balanced Budget Act or under a State health care program. [ICP Contract § 9.2.34; FHP-ACA Contract § 9.2.34]
c. Provider/Subcontractor shall not be an Excluded Person (as that term is defined below),
and shall not employ, subcontract with, or affiliate with an Excluded Person. The term “Excluded Person” means any individual or entity that (i) under Section 1128 of the Social Security Act, is or has been terminated, barred, suspended, or otherwise excluded from participation in, or as the result of a settlement agreement has voluntarily withdrawn from participation in, any program under federal law, including any program under Titles IV, XVIII, XIX, XX or XXI of the Social Security Act; (ii) has not been reinstated in the program after a period of exclusion, suspension, debarment, or ineligibility; or (iii) has been convicted of a criminal offense related to the provision of items or services to a federal, state, or local government entity within the last ten (10) years. Provider/Subcontractor acknowledges and agrees that under the State Contracts, Company must terminate its relationship with Provider/Subcontractor immediately upon learning that such Provider/Subcontractor meets the definition of an Excluded Person, and must notify the HFS OIG of the termination. [ICP Contract §§ 5.22, 9.1.32; FHP-ACA Contract §§ 5.22, 9.1.32]
d. Provider/Subcontractor acknowledges and agrees that prior to entering into the
Agreement, Company may be required to submit a disclosure statement to HFS identifying any agreements, Providers, and/or Subcontractors in which any of the following have a financial interest of five percent (5%) or more: (a) any individual or entity also having a financial interest of five percent (5%) or more in Company or Company’s affiliates as defined by 42 C.F.R. § 455.101; (b) any director, officer, trustee, partner, or employee of Company or Company’s Affiliates; and (c) any member of the immediate family of any individual or entity designated above. [ICP Contract § 5.28.12; FHP-ACA Contract § 5.28.12]
e. Provider/Subcontractor acknowledges and agrees that the State may conduct, at the
State’s expense and whenever the State deems it reasonably necessary for security reasons, criminal and driver history background checks of Provider/Subcontractor and its officers, employees, or agents, and furthermore acknowledges and agrees that Provider/Subcontractor shall immediately reassign any such individual who, in the opinion of the State, does not pass the background checks. [ICP Contract § 9.1.13; FHP-ACA Contract § 9.1.13]
21. Fraud, Abuse and Misconduct. Provider/Subcontractor shall report immediately in writing to Company and to the HFS OIG any suspected fraud, abuse, or misconduct associated with any service or function provided for under the Agreement and/or the State Contracts by any parties directly or indirectly affiliated with the Agreement and/or the State Contracts, including without limitation Company and Company’s staff, Provider/Subcontractor and its employees and subcontractors, and HFS employees or contractors. Provider/Subcontractor shall make this report to Company and to the HFS OIG within three (3) days after first suspecting fraud, abuse, or misconduct. Provider/Subcontractor shall not conduct any investigation of the suspected fraud, abuse, or misconduct without the express concurrence of the HFS OIG; the foregoing notwithstanding, Provider/Subcontractor may conduct and continue investigations necessary to determine whether reporting is required under this provision. Provider/Subcontractor must report the results of such an investigation to the HFS OIG as described above. Provider/Subcontractor shall cooperate with all investigations of suspected fraud, abuse, or misconduct reported pursuant to this provision. Nothing in this provision precludes Company or Provider/Subcontractor from establishing measures to maintain quality of services and control costs that are consistent with their usual business practices, from conducting themselves in accordance with their respective legal or contractual obligations, or from taking internal personnel-related actions. [ICP Contract §§ 5.31.1, 9.1.29; FHP- ACA Contract §§ 5.31.1, 9.1.29]
22. Offshore Services. Provider/Subcontractor is prohibited from using any individual or entity (an
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“Offshore Entity”) (including, but not limited to, any employee, contractor, subcontractor, agent, representative, or other individual or entity) to perform any services in connection with the State Contracts if the individual or entity is physically located outside of one of the fifty United States or one of the United States Territories (i.e., American Samoa, Guam, Northern Marianas, Puerto Rico, and Virgin Islands) (“Offshore Services”), unless Company, in its sole discretion and judgment, agrees in advance and in writing to the use of such Offshore Entity. Provider/Subcontractor further agrees that Company has the right to audit any Offshore Entity prior to the provision of any Offshore Services. Provider/Subcontractor further represents and warrants that it does not and will not permit any Enrollees’ protected health information (PHI) or other personal information to be accessible by any Offshore Entity, without prior written notice to Company and Company’s prior written approval of such Offshore Entity. In the event that Company agrees in advance and in writing to permit Provider/Subcontractor to use an Offshore Entity to perform any services in connection with the State Contracts and Company agrees that such Offshore Entity will receive, process, transfer, handle, store, or access Enrollee PHI as defined at 45 C.F.R. § 160.103, Provider/Subcontractor agrees that Offshore Services that involve Enrollee PHI are subject to CMS reporting within thirty (30) days of: (a) performing, or contracting with an Offshore Entity to perform, Offshore Services, and (b) any time Provider/Subcontractor changes the Offshore Services that an Offshore Entity will perform.
23. Business Enterprise Program (BEP) Registration. In the event that Provider/Subcontractor is a
minority-owned business, a female-owned business, or a business owned by persons with disabilities, then Provider/Subcontractor shall seek and obtain State certification as a Business Enterprise Program (BEP) vendor under the Business Enterprise Program Act for Minorities, Females and Persons with Disabilities. Provider/Subcontractor shall furthermore cooperate with Company with respect to Company’s obligations under the State Contract related to the Business Enterprise Program (BEP) and shall, among other things, maintain a record of all relevant data with respect to the utilization of BEP-certified individuals and entities, including, but not limited to, payroll records, invoices, canceled checks, and books of account, for a period of at least five (5) years after the completion of the Agreement. [ICP Contract §§ 2.92, 7.16.2; FHP-ACA Contract §§ 2.92, 7.16.2]
24. Marketing Activities. Provider/Subcontractor shall not engage in any inappropriate or
unallowable marketing activities and practices as set forth in the State Contracts and 42 C.F.R. § 438.104, and shall submit to Company for its review any marketing or information materials of Provider/Subcontractor that relate to the State Contracts, prior to disseminating same. Provider/Subcontractor furthermore shall not induce any employees of the State to improperly reveal any confidential information regarding Enrollees or otherwise use such confidential information in a fraudulent manner. [ICP Contract § 4.16.3; FHP-ACA Contract § 4.16.3]
25. Compliance with Laws, the State Contracts, and Company Policies and Procedures.
a. Provider/Subcontractor shall perform all services and other duties under the Agreement in accordance and compliance with, and subject to, all applicable federal, State, and local laws, rules, ordinances, regulations, orders, federal circulars, and license and permit requirements in the performance of the Agreement, including without limitation, the Managed Care Reform and Patient Rights Act (215 ILCS 134/ 1 et seq.), the federal Balanced Budget Act of 1997 (Public Law 105-33), and regulations promulgated by the Illinois Department of Financial and Professional Regulation, the Illinois Department of Public Health, and/or federal CMS. Company shall be in compliance with applicable tax requirements and shall be current in payment of such taxes. Company shall obtain at its own expense all licenses and permissions necessary for the performance of the Agreement. [ICP Contract §§ 2.2, 2.5, 9.1.12; FHP-ACA Contract §§ 2.2, 2.5, 9.1.12]
b. Provider/Subcontractor shall be bound by the terms and conditions of the State Contracts that are appropriate to the services provided by, or activities delegated to, Provider/Subcontractor in connection with the State Contracts. These terms and conditions include, without limitation, the record- keeping and audit provisions of the State Contracts, such that the Authorized Persons shall have the same rights to audit and inspect Provider/Subcontractor (and any downstream providers or subcontractors thereof) as they have to audit and inspect Company. [ICP Contract § 5.28.1.1; FHP-ACA Contract § 5.28.1.1]
c. Provider/Subcontractor shall comply with the prior-authorization requirements and
processes set forth in Company’s policies and procedures. [ICP Contract §§ 5.16.5, 5.16.6; FHP-ACA
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Contract § 5.16.5, 5.16.6]
d. Provider/Subcontractor shall comply with all utilization-management and peer-review programs, processes, and timeframes established by Company. [ICP Contract, Attachment XII ¶ 4; FHP- ACA Contract, Attachment XII ¶ 4]
26. State Employee Handbook. If Provider/Subcontractor or any of its employees and subcontractors
provide services under the Agreement at a location controlled by HFS or any other State agency, Provider/Subcontractor shall abide by all applicable provisions of the controlling State agency’s Employee Handbook. [ICP Contract § 9.1.27; FHP-ACA Contract § 9.1.27]
27. Prohibition on Gifts. Provider/Subcontractor and its principals, employees, and subcontractors are
prohibited from giving gifts to HFS employees, and from giving gifts to, or accepting gifts from, any individual or entity that has a contemporaneous contract with HFS involving duties or obligations related to the Agreement and/or the State Contracts. [ICP Contract § 9.1.30; FHP-ACA Contract § 9.1.30]
28. No Transfer of Liability to Providers. Neither Company nor Subcontractor shall transfer or
attempt to transfer to any health care provider, by indemnification, hold harmless, or contribution requirements that are set forth in any contract, written policy, or procedure, any liability relating to activities, actions, or omissions of Company and/or Subcontractor or their respective officers, employees, or agents; provided, however that nothing in this provision shall relieve any health care provider from liability for his, her, or its own negligence in the performance of his, her, or its duties arising from treatment of an Enrollee. [215 ILCS 134/95]
29. Capitated Contracts. If Company compensates Provider/Subcontractor under the Agreement on a
capitated basis for furnishing, arranging, or providing health care services:
a. Provider/Subcontractor agrees that in no event, including but not limited to nonpayment by Company of amounts due to Provider/Subcontractor under the Agreement, insolvency of Company, or any breach of the Agreement by Company, shall Provider/Subcontractor or its assignees or subcontractors have a right to or seek any type of payment from, bill, charge, collect a deposit from, or have any recourse against, the Enrollee or persons acting on the Enrollee’s behalf (other than Company) for services provided pursuant to the Agreement, except for the payment of applicable copayments or deductibles for services covered by Company or fees for services not covered by Company. The requirements of this provision shall survive any termination of the Agreement for services rendered prior to such termination, regardless of the cause of such termination. Company’s Enrollees and persons acting on the Enrollees’ behalf (other than Company) shall be third-party beneficiaries of this provision. This provision supersedes any oral or written agreement now existing or hereafter entered into between Provider/Subcontractor and the Enrollee or persons acting on the Enrollee’s behalf (other than Company). [50 Ill. Admin. Code § 5241.50(e)]
b. Provider/Subcontractor shall submit timely encounter data/records for all Covered
Services that it has provided to Enrollees, in the format specified by the State, so that Company can meet the encounter-reporting specifications and requirements set forth in the State Contracts. Provider/Subcontractor shall be responsible for transmitting all data to Company as required by 42 C.F.R. § 438. [ICP Contract § 7.11.3; FHP-ACA Contract §§ 5.6.6, 7.11.3]
c. If Provider/Subcontractor is a “Managed Care Organization” as that term is defined in 50 Ill. Admin. Code § 5241.20, Provider/Subcontractor shall submit to Company copies of Provider/Subcontractor’s quarterly financial statements, which shall include Provider/Subcontractor’s balance sheet and statements of income and cash flow within forty-five (45) days after the end of each fiscal period. In addition, Provider/Subcontractor shall submit, within ninety (90) days after the end of Provider/Subcontractor’s fiscal year, copies of Provider/Subcontractor’s audited annual financial statements prepared in accordance with generally accepted accounting principles, if available. Provider/Subcontractor acknowledges and agrees that HFS, at its discretion, may require Company to submit for HFS’s inspection the financial statements that Company has received from Provider/Subcontractor (which such financial statements shall be deemed confidential by HFS). Provider/Subcontractor agrees to fully cooperate with, and disclose all relevant information requested by,
- 17 - )
Company’s actuaries for the preparation of such actuaries’ opinion in accordance with the Actuarial Standards Board Actuarial Standards of Practice No. 16. Company acknowledges that in the event of Provider/Subcontractor’s insolvency, Company is secondarily liable as the ultimate risk bearer for unpaid health care services rendered to Company’s Enrollees. [50 Ill. Admin Code §5241.50(d)] For purposes of this provision, “Managed Care Organization” or “MCO” means a partnership, association, corporation, or other legal entity, including but not limited to individual practice associations (IPAs) and physician hospital organizations (PHOs), that delivers or arranges for the delivery of health care services through providers it has contracted with or otherwise made arrangements with to furnish those health care services. [50 Ill. Admin. Code § 5241.20]
31. Required Certifications of Provider/Subcontractor. Provider/Subcontractor acknowledges and
agrees that its compliance with Section 9.2 of each of the State Contracts and each subsection of Section 9.2 (collectively, the “Standard Certifications”) is a material requirement and condition of this Agreement during the entire term thereof, including during any renewal periods. By executing the Agreement, Provider/Subcontractor certifies compliance with the Standard Certifications in their entirety, and Provider/Subcontractor is under a continuing obligation to remain in compliance with, and to report any non-compliance with respect to, the Standard Certifications. Furthermore, Provider/Subcontractor shall include the Standard Certifications in any subcontracts or other contracts with its downstream entities or related entities that Provider/Subcontractor enters into in connection with the State Contracts. During the term of the State Contracts, Provider/Subcontractor shall confirm compliance with the Standard Certifications in the manner and format determined by the State by the date specified by the State, and in no event later than July 1 of each year that the State Contracts remains in effect. As part of each Standard Certification, Provider/Subcontractor acknowledges and agrees that if Provider/Subcontractor or its subcontractors, downstream entities, or related entities provide false information, or fail to be or remain in compliance with the Standard Certifications, one or more of the following sanctions will apply: (a) the Agreement may be void by operation of law; (b) the State may void the Agreement; and (c) Provider/Subcontractor and its subcontractors, downstream entities, or related entities may be subject to one or more of the following: suspension, debarment, denial of payment, civil fine, or criminal penalty. [ICP Contract § 9.2.1; FHP-ACA Contract § 9.2.1]
The Standard Certifications are set forth below:
a. Provider/Subcontractor certifies it and its employees will comply with applicable
provisions of the United States Civil Rights Act, Section 504 of the Federal Rehabilitation Act, the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.), and applicable rules in the performance of this Agreement. [ICP Contract § 9.2.2; FHP-ACA Contract § 9.2.2]
b. Provider/Subcontractor certifies, if applicable, that it is not in default on an educational
loan (5 ILCS 385/3). This applies to individuals, sole proprietorships, partnerships, and individuals as members of LLCs. [ICP Contract § 9.2.3; FHP-ACA Contract § 9.2.3]
c. Provider/Subcontractor (if an individual, sole proprietor, partner, or an individual as
member of an LLC) certifies, if applicable, that it has not received (i) an early retirement incentive prior to 1993 under Section 14-108.3 or 16-133.3 of the Illinois Pension Code, 40 ILCS 5/14-108.3 and 40 ILCS 5/16-133.3, or (ii) an early retirement incentive on or after 2002 under Section 14-108.3 or 16-133.3 of the Illinois Pension Code, 40 ILCS 5/14-108.3 and 40 ILCS 5/16-133 (30 ILCS 105/15a). [ICP Contract § 9.2.4; FHP-ACA Contract § 9.2.4]
d. Provider/Subcontractor certifies, if applicable, that it is a properly formed and existing
legal entity (30 ILCS 500/1.15.80, 20-43), and as applicable has obtained an assumed name certificate from the appropriate authority, or has registered to conduct business in Illinois and is in good standing with the Illinois Secretary of State. [ICP Contract § 9.2.5; FHP-ACA Contract § 9.2.5] Provider/Subcontractor certifies that it has neither been convicted of bribing or attempting to bribe an officer or employee of the State or any other state, nor made an admission of guilt of such conduct that is a matter of record (30 ILCS 500/50-5). [ICP Contract § 9.2.7; FHP-ACA Contract § 9.2.7]
e. If Provider/Subcontractor has been convicted of a felony, Provider/Subcontractor certifies
at least five (5) years have passed after the date of completion of the sentence for such felony, unless no
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person held responsible by a prosecutor’s office for the facts upon which the conviction was based continues to have any involvement with the business (30 ILCS 500/50-10). [ICP Contract § 9.2.8; FHP- ACA Contract § 9.2.8]
f. If Provider/Subcontractor, or any officer, director, partner, or other managerial agent of
Provider/Subcontractor, has been convicted of a felony under the Sarbanes-Oxley Act of 2002, or a Class 3 or Class 2 felony under the Illinois Securities Law of 1953, Provider/Subcontractor certifies that at least five (5) years have passed since the date of the conviction. Provider/Subcontractor further certifies that it is not barred from being awarded a contract and acknowledges that the State shall declare the Agreement void if this certification is false (30 ILCS 500/50-10.5). [ICP Contract § 9.2.9; FHP-ACA Contract § 9.2.9]
g. Provider/Subcontractor certifies that it is not barred from having a contract with the State
based on violating the prohibition on providing assistance to the State in identifying a need for a contract (except as part of a public request for information process) or by reviewing, drafting, or preparing a solicitation or similar documents for the State (30 ILCS 500/50-10.5e). [ICP Contract § 9.2.10; FHP-ACA Contract § 9.2.10]
h. Provider/Subcontractor certifies that it and its affiliates are not delinquent in the payment
of any debt to the State (or if delinquent has entered into a deferred payment plan to pay the debt), and Provider/Subcontractor and its affiliates acknowledge that the State may declare the Agreement void if this certification is false (30 ILCS 500/50-11) or if Provider/Subcontractor or an affiliate later becomes delinquent and has not entered into a deferred payment plan to pay off the debt (30 ILCS 500/50-60). [ICP Contract § 9.2.11; FHP-ACA Contract § 9.2.11]
i. Provider/Subcontractor certifies that it and its affiliates shall collect and remit Illinois Use
Tax on all sales of tangible personal property into the State in accordance with provisions of the Illinois Use Tax Act (30 ILCS 500/50-12) and acknowledges that failure to comply can result in the Agreement being declared void. [ICP Contract § 9.2.12; FHP-ACA Contract § 9.2.12]
j. Provider/Subcontractor certifies that it has not been found by a court or the Pollution
Control Board to have committed a willful or knowing violation of the Environmental Protection Act within the last five (5) years, and is therefore not barred from being awarded a contract (30 ILCS 500/50- 14). [ICP Contract § 9.2.13; FHP-ACA Contract § 9.2.13]
k. Provider/Subcontractor certifies that it has not paid any money or valuable thing to
induce any person to refrain from bidding on a State contract, nor has Provider/Subcontractor accepted any money or other valuable thing, or acted upon the promise of same, for not bidding on a State contract (30 ILCS 500/50-25). [ICP Contract § 9.2.14; FHP-ACA Contract § 9.2.14]
l. Provider/Subcontractor certifies that it is not in violation of the “Revolving Door” section
of the Illinois Procurement Code (30 ILCS 500/50-30). [ICP Contract § 9.2.15; FHP-ACA Contract § 9.2.15]
m. Provider/Subcontractor certifies that it has not retained a person to attempt to influence
the outcome of a procurement decision for compensation contingent in whole or in part upon the decision or procurement (30 ILCS 500/50-38). [ICP Contract § 9.2.16; FHP-ACA Contract § 9.2.16]
n. Provider/Subcontractor certifies that it will report to the Illinois Attorney General and the Chief Procurement Officer any suspected collusion or other anti-competitive practice among any bidders, offerors, contractors, proposers, or employees of the State (30 ILCS 500/50-40, 50-45, 50-50). [ICP Contract § 9.2.17; FHP-ACA Contract § 9.2.17]
o. In accordance with the Steel Products Procurement Act, Provider/Subcontractor certifies
that steel products used or supplied in the performance of a contract for public works shall be manufactured or produced in the United States, unless the executive head of the procuring agency grants an exception (30 ILCS 565). [ICP Contract § 9.2.18; FHP-ACA Contract § 9.2.18]
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p. If Provider/Subcontractor employs twenty-five (25) or more employees, Provider/Subcontractor certifies that it will provide a drug free workplace pursuant to the Drug Free Workplace Act (30 ILCS 580). [ICP Contract § 9.2.19; FHP-ACA Contract § 9.2.19]
q. Provider/Subcontractor certifies that neither Provider/Subcontractor nor any substantially
owned affiliate of Provider/Subcontractor is participating or shall participate in an international boycott in violation of the U.S. Export Administration Act of 1979 or the applicable regulations of the U.S. Department of Commerce (30 ILCS 582). [ICP Contract § 9.2.20; FHP-ACA Contract § 9.2.20]
r. Provider/Subcontractor certifies that it has not been convicted of the offense of bid
rigging or bid rotating or any similar offense of any state or of the United States (720 ILCS 5/33E-3, E-4). [ICP Contract § 9.2.21; FHP-ACA Contract § 9.2.21]
s. Provider/Subcontractor certifies that it complies with the Illinois Department of Human
Rights Act and rules applicable to public contracts, including equal employment opportunity, refraining from unlawful discrimination, and having written sexual harassment policies (775 ILCS 5/2-105). [ICP Contract § 9.2.22; FHP-ACA Contract § 9.2.22]
t. Provider/Subcontractor certifies that it does not pay dues to or reimburse or subsidize
payments by its employees for any dues or fees to any “discriminatory club” (775 ILCS 25/2). [ICP Contract § 9.2.23; FHP-ACA Contract § 9.2.23]
u. Provider/Subcontractor certifies that it complies with the State Prohibition of Goods from
Forced Labor Act, and certifies that no foreign-made equipment, materials, or supplies furnished to the State under the Agreement have been or will be produced in whole or in part by forced labor, or indentured labor under penal sanction (30 ILCS 583). [ICP Contract § 9.2.24; FHP-ACA Contract § 9.2.24]
v. Provider/Subcontractor certifies that no foreign-made equipment, materials, or supplies
furnished to the State under the Agreement have been produced in whole or in part by the labor or any child under the age of twelve (30 ILCS 584). [ICP Contract § 9.2.25; FHP-ACA Contract § 9.2.25]
w. Provider/Subcontractor certifies that it is not in violation of Section 50-14.5 of the Illinois
Procurement Code (30 ILCS 500/50-14.5), which states: “Owners of residential buildings who have committed a willful or knowing violation of the Lead Poisoning Prevention Act (410 ILCS 45) are prohibited from doing business with the State until the violation is mitigated.” [ICP Contract § 9.2.26; FHP-ACA Contract § 9.2.26]
x. Provider/Subcontractor warrants and certifies that it and, to the best of its knowledge, its
subcontractors, downstream entities, or related entities, have and will comply with Executive Order No. 1 (2007). That Order generally prohibits contractors and subcontractors from hiring the then-serving Illinois Governor’s family members to lobby procurement activities of the State, or any other unit of government in the State including local governments if that procurement may result in a contract valued at over $25,000. This prohibition also applies to hiring for that same purpose any former State employee who had procurement authority at any time during the one-year period preceding the procurement lobbying activity. [ICP Contract § 9.2.27; FHP-ACA Contract § 9.2.27]
y. Provider/Subcontractor certifies that information technology, including electronic information, software, systems, and equipment developed or provided under the Agreement will comply with the applicable requirements of the Illinois Information Technology Accessibility Act Standards as published at www.dhs.state.il.us/iitaa (30 ILCS 587). [ICP Contract § 9.2.28; FHP-ACA Contract § 9.2.28]
aa. Provider/Subcontractor certifies that it is not currently barred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal or State department or agency, and is not currently barred or suspended from contracting with the State under Section 50-35(f), 50-35(g) or 50-65 of the Illinois Procurement Code, 30 ILCS 500/1-1 et seq. If at
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any time during the term of the Agreement, Provider/Subcontractor becomes barred, suspended, or excluded from participation in this transaction, Provider/Subcontractor shall, within thirty (30) days after becoming barred, suspended, or excluded, provide to HFS a written description of each offense causing the exclusion, the date(s) of the offense(s), the action(s) causing the offense(s), any penalty assessed or sentence imposed, and the date any penalty was paid or sentence completed. [ICP Contract § 9.2.29; FHP- ACA Contract § 9.2.29]
bb. Provider/Subcontractor certifies that neither Provider/Subcontractor, nor any party
directly or indirectly affiliated with Provider/Subcontractor, including but not limited to Provider/Subcontractor’s officers, directors, employees, and subcontractors, and the officers, directors, and employees of Provider/Subcontractor’s subcontractors, shall have or acquire any Conflict of Interest (as defined below) in performance of the Agreement. Provider/Subcontractor shall disclose in writing any Conflicts of Interest to HFS no later than seven (7) days after learning of the Conflict of Interest. HFS may initiate any inquiry as to the existence of a Conflict of Interest, and Provider/Subcontractor shall cooperate with all such inquiries. HFS shall determine, in its sole discretion, whether a Conflict of Interest exists or whether Provider/Subcontractor failed to make any required disclosure. If HFS concludes that a Conflict of Interest exists, or that Provider/Subcontractor failed to disclose any Conflict of Interest, HFS may impose one or more remedies in its sole discretion, including without limitation the elimination of the Conflict of Interest or the non-renewal or termination of the Agreement. [ICP Contract § 9.2.30; FHP-ACA Contract § 9.2.30]
i. For purposes of this provision, “Conflict of Interest” shall mean an interest of
Provider/Subcontractor, or any entity described above, which may be direct or indirect, professional, personal, financial, or beneficial in nature that, in the sole discretion of HFS, compromises, appears to compromise, or gives the appearance of impropriety with regard to Provider/Subcontractor’s duties and responsibilities under the Agreement. This term shall include potential Conflicts of Interest. A Conflict of Interest may exist even if no unethical or improper act results from it or may arise where Provider/Subcontractor becomes a party to any litigation, investigation, or transaction that materially impacts Provider/Subcontractor’s ability to perform under the Agreement. Any situation where Provider/Subcontractor’s role under the Agreement competes with Provider/Subcontractor’s professional or personal role may give rise to an appearance of impropriety. Any conduct that would lead a reasonable individual, knowing all the circumstances, to a conclusion that bias may exist or that improper conduct may occur, or that gives the appearance of the existence of bias or improper conduct, is a Conflict of Interest. [ICP Contract § 9.2.30.1; FHP-ACA Contract § 9.2.30.1]
cc. Provider/Subcontractor certifies that it is in compliance with all applicable standards,
orders, or regulations issued pursuant to the federal Clean Air Act (42 U.S.C. § 7401 et seq.) and the federal Water Pollution Control Act (33 U.S.C. § 1251 et seq.). Violations shall be reported to the United States Department of Health and Human Services and the appropriate Regional Office of the United States Environmental Protection Agency. [ICP Contract § 9.2.31; FHP-ACA Contract § 9.2.31]
dd. Provider/Subcontractor certifies that, to the best of its knowledge and belief, no federally
appropriated funds have been paid or will be paid by or on behalf of Provider/Subcontractor, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal loan or grant, or the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, Provider/Subcontractor shall complete and submit Standard Form LLL, “Disclosure Forms to Report Lobbying,” in accordance with its instructions. Such form is to be obtained at Provider/Subcontractor’s request from the HFS Bureau of Fiscal Operations. Provider/Subcontractor shall require that the language of this certification be included in the award document for sub-awards at all tiers (including subcontracts,
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sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when the Agreement was executed. Submission of this certification is a prerequisite for making or entering into the transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. [ICP Contract § 9.2.32; FHP-ACA Contract § 9.2.32]
ee. Provider/Subcontractor certifies that it has read, understands, and is in compliance with
the registration requirements of the Elections Code (10 ILCS 5/9-35) and the restrictions on making political contributions and related requirements of the Illinois Procurement Code (30 ILCS 500/20-160 and 50-37). Provider/Subcontractor will not make a political contribution that will violate these requirements, which are effective for the duration of the term of office of the incumbent State governor or for a period of two (2) years after the end of the Agreement’s term, whichever is longer. Provider/Subcontractor will certify, as applicable, either that it is not required to register as a business entity with the State Board of Elections, or has registered with the State Board of Elections and will appropriately and timely update that registration. [ICP Contract § 9.2.33 & Attachment X; FHP-ACA Contract § 9.2.33 & Attachment X]
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ADDENDUM B
Regulatory Compliance Addendum Governing Medicare-Medicaid Dual-Eligible Services
This Regulatory Compliance Addendum Governing Medicare-Medicaid Dual-Eligible Services (the “Duals Addendum”) shall govern the provision of Covered Services to Members dually eligible for both Medicare and Medicaid under the Contract Between United States Department of Health and Human Services Centers for Medicare & Medicaid Services, In Partnership with the State of Illinois Department of Healthcare and Family Services and an MCO (the “Three-Way Contract”), which established and governs the program known as the Illinois Medicare-Medicaid Alignment Initiative a/k/a the MMAI (the “MMAI”) and under which a (“Company”) serves as a managed care organization, as well as the provision of any administrative or health-benefit management services/functions that relate to those Covered Services or to the Three-Way Contract and/or the MMAI.
This Duals Addendum is incorporated by reference into the Agreement between Company (or its Affiliate, as the case may be) and the provider, vendor, contractor, or other entity executing the Agreement, as identified on the first page of the Agreement (the “Provider”), and Provider must comply with the requirements set forth herein. Note that this Duals Addendum contains some, but not all, of the terms and requirements with which you must comply. Other terms and requirements with which you must comply are set forth in the Agreement, in the Three-Way Contract, and in the policies, procedures, and provider manual of Company (or its Affiliate, as the case may be). This Duals Addendum and the Agreement may be revised as directed by the State of Illinois and/or by the Centers for Medicare and Medicaid Services.
For purposes of this Duals Addendum, Company may be referred to as “MCO” or “the MCO” (a/k/a managed care organization), and the individuals who are enrolled with Company under the MMAI may be referred to as the “Members” or “Enrollees.” All capitalized terms not defined in this Duals Addendum shall have the respective meanings that are ascribed to them in the Agreement.
If there is any conflict between the terms of this Duals Addendum and any of the other terms of this Agreement, including any attachments, schedules, exhibits, and/or addenda made part of this Agreement, the terms of this Duals Addendum will govern and control with respect to the provision of Covered Services to Members dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI, and with respect to the provision of any administrative or health-benefit management services/functions that relate to those Covered Services or to the Three-Way Contract and/or the MMAI; provided, however, that if there is any conflict between any of the terms of this Agreement, including this Duals Addendum, and the Three-Way Contract, then the terms of the Three-Way Contract will govern and control. Except as provided herein, all other provisions of the Agreement not inconsistent with this Duals Addendum shall remain in full force and effect, and to the extent possible under applicable law, the terms of this Duals Addendum shall be construed to be supplementary to, and not in conflict with, the terms and conditions of the Three-Way Contract and the remainder of the Agreement.
Provider acknowledges and agrees that all provisions of this Duals Addendum shall apply equally to any employees, independent contractors, subcontractors, downstream entities, or related entities of Provider that provide Covered Services to Members dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI, or that provide administrative or health-benefit management services/functions that relate to those Covered Services or to the Three-Way Contract and/or the MMAI, and Provider represents and warrants that Provider shall take all steps necessary to cause such employees, independent contractors, subcontractors, downstream entities, or related entities to comply with this Duals Addendum and all applicable laws and regulations.
REQUIREMENTS FOR THE MMAI
A. Illinois State Requirements
The State of Illinois requires that specific terms and conditions be incorporated into the Agreement. As such, Provider shall comply with, and shall cause its downstream entities and related entities to comply with, the following
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requirements with respect to the provision of Covered Services to Members dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI, and with respect to the provision of administrative or health-benefit management services/functions (or other functions delegated to Provider) that relate to those Covered Services or to the Three-Way Contract and the MMAI:
1. Hold Harmless of Enrollees. Provider agrees that in no event, including but not limited to the
nonpayment by Company of amounts due to Provider under the Agreement, the insolvency of Company, or any breach of the Agreement by Company, shall Provider or its assignees or subcontractors have a right to seek any type of payment from, bill, charge, collect a deposit from, or have any recourse against the Member or persons acting on the Member’s behalf (other than Company) for services provided pursuant to the Agreement except for the payment of applicable copayments or deductibles for services covered by Company or fees for services not covered by Company. The requirements of this provision shall survive any termination of the Agreement for services rendered prior to such termination, regardless of the cause of such termination. Company’s Members and all persons acting on the Members’ behalf (other than Company) shall be third-party beneficiaries of this provision. This provision supersedes any oral or written agreement now existing or hereafter entered into between Provider and the Member or persons acting on the Member’s behalf (other than Company). [215 ILCS 125/2-8(a)]
2. Quality Assurance. Provider shall provide, arrange for, or participate in the quality-assurance
programs mandated by the Illinois Health Maintenance Organization Act, unless the Illinois Department of Public Health has certified that such programs will be fully implemented without any participation or action from Provider. [215 ILCS 125/2-8(a); 50 Ill. Admin. Code § 5241.50(a)(4)]
3. Termination of Agreement. Notwithstanding anything in the Agreement to the contrary, if either
Company or Provider seeks (i) to terminate the Agreement “with cause” (as that term is used and defined in the Agreement), the terminating party shall provide at least sixty (60) days’ written notice to the other party; or (ii) to terminate the Agreement “without cause” (as that term is used and defined in the Agreement), the terminating party shall provide at least ninety (90) days’ written notice to the other party. Furthermore, Provider shall cooperate with Company with respect to Company’s obligation to provide timely notice to Enrollees of any termination that would curtail or eliminate services to such Enrollees, with such notice to be sent (i) at least sixty (60) days prior to that termination, or (ii) immediately, if Company receives less than sixty (60) days’ notice of that termination from Provider. The notice to be sent to Enrollees shall include instructions regarding referrals that have previously been issued and appointments that may be pending. [50 Ill. Admin. Code § 5241.50(a)(5)–(6); 305 ILCS 5/5F-40(a)]
4. No Discrimination. Provider will not discriminate against Enrollees or potential Enrollees on the
basis of payment source. [77 Ill. Admin. Code § 240.50(d)(4)]
5. Anti-Gag Clause; Prohibition on Retaliation. Provider shall not be prohibited or otherwise restricted or discouraged from, and shall not prohibit or otherwise restrict or discourage its downstream providers or subcontractors from, taking any of the following actions so long as those actions are within the lawful scope of the acting party’s practice: (a) advocating for medically appropriate health care services for Enrollees, which may include without limitation appealing denials and protesting decisions, policies, and practices; and/or (b) discussing with Enrollees, prospective Enrollees, or the public any health care services, health care providers, utilization review policies, quality assurance policies, or terms and conditions of plans and plan policy. Furthermore, Company shall not retaliate against Provider, and Provider shall not retaliate against its downstream providers or subcontractors, for any of the foregoing actions. Notwithstanding the foregoing, nothing in this provision shall be construed to prohibit: (a) Company or Provider from making a determination not to pay for a particular health care service, from enforcing reasonable peer review or utilization review protocols, or from determining whether a physician or other health care provider has complied with those protocols; and/or (b) a Provider that is a hospital from taking disciplinary actions against a physician as authorized by law. [215 ILCS 134/30(a); 215 ILCS 134/35(a)–(d)]
6. Cooperation with Company. Provider shall cooperate with Company with respect to Company’s
obligations and responsibilities relating to the “HMO self-evaluation structure” and associated activities set forth in 77 Ill. Admin. Code § 240.60. [77 Ill. Admin. Code § 240.50(d)(1)(C)]
7. Pharmacy Benefits. Company and Provider shall not permit or allow, whether by contract, written
policy, or procedure, any individual or entity to dispense a different drug in place of the drug or brand of drug
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ordered or prescribed without the express permission of the person ordering or prescribing the drug, except as provided under Section 3.14 of the Illinois Food, Drug and Cosmetic Act (codified at 410 ILCS 620/3.14). [215 ILCS 134/30(b)]
8. Use of Hospitalists. Neither Company nor Provider shall require or otherwise mandate, whether
by contract, written policy, or procedure, any Enrollee to substitute his or her participating primary care provider (PCP) during inpatient hospitalization, such as with a hospitalist physician, without the agreement of that Enrollee’s participating primary care provider (PCP). Company and Provider (if applicable) shall inform Enrollees of any policies, recommendations, or guidelines concerning the substitution of the Enrollee’s primary care provider (PCP) when hospitalization is necessary in the manner set forth in 215 ILCS 5/15(d)–(e). [215 ILCS 134/30(c)]
9. No Transfer of Liability to Downstream Providers. Neither Company nor Provider shall transfer
or attempt to transfer to any health care provider, by indemnification, hold harmless, or contribution requirements that are set forth in any contract, written policy, or procedure, any liability relating to activities, actions, or omissions of Company and/or Provider or their respective officers, employees, or agents; provided, however that nothing in this provision shall relieve any health care provider from liability for his, her, or its own negligence in the performance of his, her, or its duties arising from treatment of an Enrollee. [215 ILCS 134/95]
10. Medical Records. With respect to Enrollee medical records:
a. Provider shall maintain Enrollee medical records in a timely, legible, accurate, current, complete, and organized manner, with appropriate dates and identification and initialing/signature of the Provider, to facilitate retrieval and compilation of records and to ensure Enrollee continuity of care. For each encounter or episode of care that Provider has with an Enrollee, Provider shall place the following information into the Enrollee’s medical records: (1) the reason for the encounter; (2) evidence of the Provider’s assessment of the Enrollee’s health problems; (3) current diagnosis of the Enrollee, including the results of any diagnostic tests; (4) the plan of treatment, including any therapies and health education; (5) any medical history relevant to the current episode of care; and (6) confirmation that all outcomes of ancillary reports, such as laboratory tests and x-rays, have been reviewed by the individual or entity who ordered the reports and that follow-up actions have been taken regarding report results that are deemed significant by the individual or entity who ordered those reports. [77 Ill. Admin. Code §§ 240.50(c)(1), 240.90(a)–(b)]
b. If Provider is an Enrollee’s primary care provider (PCP), Provider shall furthermore
maintain an Enrollee medical record that contains, with respect to each routine, scheduled appointment with that primary care provider (PCP): (1) identification; (2) patient history; (3) known past surgical procedures; (4) known past and current diagnoses and problems; and (5) known allergies and untoward reactions to drugs. [77 Ill. Admin. Code § 240.90(c)]
11. Capitated Contracts. If Company compensates Provider under the Agreement on a capitated basis
for furnishing, arranging, or providing health care services:
a. Provider agrees that in no event, including but not limited to nonpayment by Company of amounts due to Provider under the Agreement, insolvency of Company, or any breach of the Agreement by Company, shall Provider or its assignees or subcontractors have a right to or seek any type of payment from, bill, charge, collect a deposit from, or have any recourse against, the Member or persons acting on the Member’s behalf (other than Company) for services provided pursuant to the Agreement, except for the payment of applicable copayments or deductibles for services covered by Company or fees for services not covered by Company. The requirements of this provision shall survive any termination of the Agreement for services rendered prior to such termination, regardless of the cause of such termination. Company’s Members and persons acting on the Members’ behalf (other than Company) shall be third-party beneficiaries of this provision. This provision supersedes any oral or written agreement now existing or hereafter entered into between Provider and the Member or persons acting on the Member’s behalf (other than Company). [50 Ill. Admin. Code § 5241.50(e)]
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b. If Provider is a “Managed Care Organization” as that term is defined in 50 Ill. Admin. Code § 5241.20, Provider shall submit to Company copies of Provider’s quarterly financial statements, which shall include Provider’s balance sheet and statements of income and cash flow within forty-five (45) days after the end of each fiscal period. In addition, Provider shall submit, within ninety (90) days after the end of Provider’s fiscal year, copies of Provider’s audited annual financial statements prepared in accordance with generally accepted accounting principles, if available. Provider acknowledges and agrees that the Illinois Department for Healthcare and Family Services (“HFS”), at its discretion, may require Company to submit for HFS’s inspection the financial statements that Company has received from Provider (which such financial statements shall be deemed confidential by HFS). Provider agrees to fully cooperate with, and disclose all relevant information requested by, Company’s actuaries for the preparation of such actuaries’ opinion in accordance with the Actuarial Standards Board Actuarial Standards of Practice No. 16. Company acknowledges that in the event of Provider’s insolvency, Company is secondarily liable as the ultimate risk bearer for unpaid health care services rendered to Company’s Enrollees. [50 Ill. Admin Code §5241.50(d)] For purposes of this provision, “Managed Care Organization” or “MCO” means a partnership, association, corporation, or other legal entity, including but not limited to individual practice associations (IPAs) and physician hospital organizations (PHOs), that delivers or arranges for the delivery of health care services through providers it has contracted with or otherwise made arrangements with to furnish those health care services. [50 Ill. Admin. Code § 5241.20]
B. Medicare Requirements
Without limiting any obligation of Provider under the Agreement, Provider shall comply with, and shall cause its Downstream Entities and Related Entities to comply with, the requirements set forth in this Section B with respect to the provision of Covered Services to Members dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI, and with respect to the provision of administrative or health-benefit management services/functions (or other functions delegated to Provider), as applicable, that relate to those Covered Services or to the Three-Way Contract and the MMAI (the “Medicare Services”). (The terms “Downstream Entities” and “Related Entities” shall have the respective meanings that are ascribed to them in Schedule 1 hereto, and shall include Provider’s permanent and temporary employees.) For purposes of this Section B, the Members dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI shall collectively be referred to as the “Medicare Members,” and the managed-care plan that MCO offers under the Three-Way Contract and the MMAI shall be referred to as the “Medicare Plan.” Provider’s obligations specifically include, and Provider expressly agrees to comply with, the following:
1. PAYMENT.
A. In consideration of Provider’s agreement to perform Covered Services in accordance with the Agreement, Provider shall be paid for Covered Services performed according to the terms of the applicable Services and Compensation Schedule (or other analogous compensation schedule appended to the Agreement).
B. MCO shall not pay any amounts beyond the amounts set forth in the applicable Services
and Compensation Schedule (or other analogous compensation schedule appended to the Agreement), including but not limited to any incentive payments that may be payable under traditional Medicare, except as expressly required by the Agreement or applicable law. Further, the Parties acknowledge and agree that payments under the Medicare program to providers, suppliers, and MCO may be adjusted as the result of legislation, regulation, executive order, or other federal mandate (“Medicare Payment Adjustment”). Furthermore, any such Medicare Payment Adjustment could result in an increase or decrease in Medicare payments. In accordance with the terms of this Agreement, the Parties agree that, in the event of a Medicare Payment Adjustment, MCO’s payment to Provider will be adjusted in accordance with the Medicare Payment Adjustment. MCO shall adjust payments under this Agreement for Covered Services rendered by Provider on and after the effective date of the Medicare Payment Adjustment, and shall continue to adjust payments to Provider for Covered Services until the earlier of (i) the discontinuation of the Medicare Payment Adjustment, or (ii) the replacement of the Medicare Payment Adjustment by a subsequent Medicare Payment Adjustment.
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C. Pursuant to Section B.5.K. of this Duals Addendum, Provider certifies that the diagnosis codes submitted to MCO for Medicare Members that MCO is required to submit to CMS will be accurate, complete, and truthful (the “Certification”). Provider acknowledges and agrees that MCO may impose a penalty on Provider not to exceed five thousand dollars ($5,000) for each instance that Provider submits a diagnosis code to MCO for a Medicare Member that does not comply with this Certification because the diagnosis code was not submitted in the format described in 42 C.F.R. § 422.310 or any subsequent or additional federal regulations. For purposes of this Section, “diagnosis code” shall mean an International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM) code or its successor.
D. Federal laws and regulations limit the timeframe within which CMS may recover
overpayments made to physicians, providers, and suppliers who submit claims to Medicare contractors (such as fiscal intermediaries, regional home health intermediaries, carriers, Medicare Administrative Contractors, and Durable Medical Equipment Medicare Administrative Contractors) for services provided or supplied to Medicare beneficiaries enrolled in Original Medicare (the “Medicare Statute of Limitations”). If MCO makes an overpayment or payment in error to Provider for Medicare Members, MCO shall have the right to initiate overpayment recovery efforts within the same timeframe available to CMS under the Medicare Statute of Limitations; provided that no time limit shall apply to initiation of overpayment recovery efforts based on MCO’s reasonable suspicion of fraud or other intentional misconduct.
E. In no event, including without limitation non-payment by MCO, insolvency of MCO, or
breach of the Agreement, shall Provider bill, charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse against a Medicare Member or persons (other than MCO) acting on a Medicare Member’s behalf for services covered under the Agreement. Provider further agrees that: (i) this provision shall survive termination of the Agreement regardless of the cause giving rise to termination and shall be construed for the benefit of Medicare Members, and (ii) this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into between Provider and a Medicare Member or persons acting on a Medicare Member’s behalf. No modification of this provision shall be effective without the prior written approval of the appropriate regulatory entities.
2. ASSIGNMENT. In addition to all other rights of MCO under the Agreement, the Agreement
(including, but not limited to, as it relates to the line(s) of business described in this Duals Addendum) may be assigned by MCO, at any time and from time to time, in whole or in part, to any other affiliate or successor in interest of MCO. At MCO’s option, the Agreement shall survive, without any other change in its terms, as a distinct, separate agreement with MCO for those products/lines of business designated by MCO and in duplicate form as a separate, distinct participating provider agreement with the applicable affiliate(s)/successor(s) for the products/lines of business assigned to such entity(ies). In the event of any assignment under this paragraph, MCO shall provide advance written notice to Provider. In the event of a conflict between this Section and any other provision of the Agreement, the terms of this Section shall supersede and prevail.
3. EFFECT OF TERMINATION. In the event this Duals Addendum is terminated for any reason,
such termination shall not constitute termination of any of MCO’s other products, plans, or programs.
4. MEDICARE REQUIRED PROVISIONS. Provider agrees to comply with all of the provisions of the Schedules attached hereto and incorporated into this Duals Addendum (including Schedule 1 and any delegated function-specific Schedules that may be appended hereto), and agrees that all terms and conditions in the Agreement applicable to Provider shall also apply to any Downstream Entities of Provider. Provider further acknowledges and agrees that all terms of such Schedules shall apply equally to services provided in connection with the Three-Way Contract and the MMAI, even if such Schedules only refer to Medicare Advantage products. Provider acknowledges that to the extent MCO is delegating to Provider any activities and responsibilities in connection with the Three-Way Contract and the MMAI, MCO may only delegate such activities and responsibilities in a manner consistent with the contractual and legal obligations and duties imposed on MCO under the Three-Way Contract and under applicable Medicare laws, regulations, rules, and other directions of CMS.
5. PROVIDER OBLIGATIONS.
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A. Provision of Covered Services. Provider agrees to provide to Medicare Members the health care services for which Provider is licensed and customarily provides in accordance with accepted medical and surgical standards in the community. Provider shall make Covered Services available and accessible to Medicare Members, including telephone access to Provider, on a twenty-four (24) hours, seven (7) days per week basis.
B. Compliance; Cooperation. Provider agrees that all Medicare Services and other activities
performed by Provider under the Agreement will be consistent and comply with MCO’s obligations under the Three-Way Contract. Upon request, Provider shall immediately provide to MCO any information that is required by MCO to meet its reporting obligations to CMS, including without limitation, physician incentive plan information, if applicable. To the extent that Provider generates and/or compiles and provides any data to MCO that MCO, in turn, submits to CMS, Provider certifies, to the best of its knowledge and belief, that such data is accurate, complete, and truthful. Provider agrees to cooperate with and participate in internal and external review procedures necessary to allow MCO to process Medicare appeals and grievances in accordance with Medicare laws, regulations, and CMS instructions.
C. Federal Fund Obligations. Provider understands and agrees that payments received by
MCO for the Medicare Plan from CMS pursuant to the Three-Way Contract, as well as payments that Provider receives from MCO for performing services and functions under the Agreement, constitutes the receipt of federal funds. As a result, Provider, by entering into this Agreement and the terms of this Duals Addendum, is subject to laws applicable to individuals/entities receiving federal funds, including but not limited to, Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 C.F.R. part 84, the Age Discrimination Act of 1975 as implemented by regulations at 45 C.F.R. part 91, the Rehabilitation Act of 1973, and the Americans with Disabilities Act.
D. Continuation of Services. In the event the Three-Way Contract terminates or MCO
becomes insolvent, Provider shall continue to provide Covered Services to Medicare Members who are hospitalized through the date of discharge. Provider is prohibited by law from billing Medicare Members for such Covered Services. This provision shall survive the termination of this Agreement or Duals Addendum, regardless of the reason for termination, including the insolvency of MCO, and shall supersede any oral or written agreement between Provider and a Medicare Member.
E. Policies, Programs & Procedures. Provider agrees to comply with MCO’s policies and
procedures (which MCO shall provide to Provider upon request) which operationalize many of the requirements of the Agreement, this Duals Addendum, and the Three-Way Contract and MMAI. Provider agrees to comply with MCO’s quality improvement, administrative processes and procedures, utilization review, peer review, grievance procedures, credentialing and recredentialing procedures, and any other policies MCO may implement, including amendments made to the above mentioned policies, procedures and programs from time to time. In the event that an MCO policy or procedure conflicts with a provision in the Agreement, then the language in the Agreement (including all amendments, exhibits, and attachments thereto) shall govern.
F. Maintenance of Records. Provider, on behalf of itself and its Downstream Entities (if
any), shall preserve records applicable to Medicare Members or to MCO’s participation in the Three-Way Contract and MMAI, for the longer of: (i) the period of time required by state and federal law, or (ii) ten (10) years, whichever is longer. In addition, to the extent applicable to Provider, Provider, on behalf of itself and any Downstream Entities with whom Provider has contracted, agrees to comply with 42 C.F.R. § 422.2480(c) and 42 C.F.R. § 423.2480(c) and to maintain all records containing data used by MCO to calculate Medicare medical loss ratios (“MLRs”) for MCO’s Medicare products and/or evidence needed by MCO and/or federal governmental authorities with jurisdiction to validate MLRs (collectively, “MLR Records”) for a minimum of ten (10) years from the date such MLRs were reported by MCO to CMS. Provider further agrees that with respect to Medicare Plans, MCO and federal governmental authorities having jurisdiction, and their designees, upon request, shall have access to all MLR Records, and that this right of inspection, evaluation, and audit of MLR Records shall continue for a minimum of ten (10) years
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from the date such MLRs were reported by MCO to CMS. This provision shall survive the termination of the Agreement, regardless of the cause of termination.
G. Subcontractors. Provider shall require all of its subcontractors, if any, to comply with all
applicable Medicare laws, regulations and CMS instructions.
(1) Provider shall include in Provider’s contracts with subcontractors (a) all of the contractual and legal obligations and duties imposed on Provider in the Agreement, (b) all provisions required under Medicare laws, regulations, rules, and other directions of CMS (including all of MCO’s obligations under such laws, regulations, rules, and other directions related to the scope of Provider’s services under the Agreement), and (c) that any delegated services or activities to be performed by subcontractor shall be consistent and comply with the obligations in the Three-Way Contract. To the extent CMS requires additional provisions to be included in such subcontracts, Provider shall amend its contracts accordingly. Provider acknowledges that, with respect to any services or functions under the Agreement that Provider delegates to a subcontractor, such subcontractor shall be considered a Downstream Entity.
(2) Provider shall ensure that any vendors, subcontractors, or other such entities that
have a need to know the terms of the Agreement also maintain the privacy and confidentiality of all financial terms of the Agreement.
(3) If Provider arranges for the provision of Covered Services from other health care
providers for Medicare Members, such contracts shall be in writing and shall specify the delegated activities and reporting responsibilities, in addition to meeting the requirements described above. In the event that MCO delegates to Provider the selection of providers, MCO retains the right to approve, suspend or terminate such delegation. If MCO delegates the selection of providers, MCO will either review the credentials of medical professionals affiliated with Provider or MCO will review, approve, and audit on an ongoing basis Provider’s credentialing process.
The term “Subcontractor” as used in this Section shall not refer to employees or other individuals
that perform services on behalf of Provider for which Provider bills such services under this Agreement. Provider represents and warrants that such persons are subject to all terms and conditions of this Agreement and Provider shall provide written evidence of such as described in the Agreement.
H. Contracts with Excluded Entities. Provider understands and agrees that no person that
provides health care services and/or utilization review, medical social work, or administrative services in support of services billed under this Agreement by Provider, may be an individual excluded from participation in Medicare under Section 1128 or 1128A of the Social Security Act. Provider shall not employ or contract with, with or without compensation, any individual or entity that has been disbarred, excluded, suspended or otherwise determined to be ineligible to participate in a federal health care program. Provider hereby certifies that no such excluded person will provide such services under this Agreement and no such excluded persons will be employed by or utilized by any Downstream Entity with which Provider contracts relating to the furnishing of these services to Medicare Members. Furthermore, neither Provider nor any of Provider’s Downstream Entities who are and/or will be fully or partially responsible for Provider’s performance of its obligations under the Agreement has (i) pled guilty or no contest to or been convicted of any felony involving dishonesty or breach of trust; (ii) been excluded from participation in any federal or state funded health program; or (iii) been listed in the Department of Health and Human Services Office of Inspector (“OIG”) exclusion list or the General Services Administrative (“GSA”) exclusion list. Provider agrees to immediately notify MCO in the event that Provider or any of its Downstream Entities that assist or are involved in Provider’s performance of services for Medicare Plans under the Agreement are or become disbarred, excluded, suspended, or otherwise determined to be ineligible to participate in a federal health care program. In accordance with applicable laws, rules, and regulations and the Compliance Program Guidelines, Provider agrees to review the Department of Health and Human Services (“HHS”) Office of Inspector General List of Excluded Individuals and Entities and the General Service Administrative Excluded Parties Lists System (collectively, the “Exclusion Lists”) to ensure that Provider Related Parties are not included on such Exclusion Lists. Provider agrees to review
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the Exclusion Lists prior to initially hiring, appointing, or contracting with any new Provider Related Party and at least once per month thereafter to confirm that Provider Related Parties are not included on such Exclusion Lists. Provider agrees that if a Provider Related Party appears on an Exclusion List and/or is excluded from participation in any federally-funded health program, Provider will immediately remove the Provider Related Party from any work related directly or indirectly to the Medicare Plan, and take all corrective actions required under applicable laws, rules or regulations. In the event Provider or any Provider Related Parties are listed in an Exclusion List after the Effective Date of this Duals Addendum, MCO shall have the right, in its sole discretion and judgment, to terminate this Duals Addendum in accordance with the Agreement or to disqualify the listed person(s) from providing any part of the Covered Services. For the purpose of this Section, “Provider Related Parties” means Provider’s permanent and temporary employees and Downstream Entities that are involved in the performance of Medicare Services.
I. Offshore Services. Provider is prohibited from using any individual or entity (an
“Offshore Entity”) (including, but not limited to, any employee, contractor, subcontractor, agent, representative, or other individual or entity) to perform any services for the Medicare Plan if the individual or entity is physically located outside of one of the fifty United States or one of the United States Territories (i.e., American Samoa, Guam, Northern Marianas, Puerto Rico, and Virgin Islands) (“Offshore Services”), unless MCO, in its sole discretion and judgment, agrees in advance and in writing to the use of such Offshore Entity. Provider further agrees that MCO has the right to audit any Offshore Entity prior to the provision of Offshore Services for the Medicare Plan. Provider further represents and warrants that it does not and will not permit any Medicare Members’ protected health information (PHI) or other personal information to be accessible by any Offshore Entity, without prior written notice to MCO and MCO’s prior written approval of such Offshore Entity. In the event that MCO agrees in advance and in writing to permit Provider to use an Offshore Entity to perform any services for Medicare Plans and MCO agrees that such Offshore Entity will receive, process, transfer, handle, store, or access Medicare Member PHI as defined at 45 C.F.R. § 160.103, Provider agrees that Offshore Services that involve Medicare Member PHI are subject to CMS reporting within thirty (30) days of: (1) performing, or contracting with an Offshore Entity to perform, Offshore Services, and (2) any time Provider changes the Offshore Services that an Offshore Entity will perform.
J. Submission of Encounter Data. Provider hereby acknowledges that MCO is required to
provide CMS and other federal and state regulatory agencies and accrediting organizations with encounter data as requested by such agencies and organizations. Such data may include medical records and all other data necessary to characterize each encounter between Provider and a Medicare Member. Provider agrees to cooperate with MCO and to provide MCO with all such information in such form and manner as requested by MCO. Provider agrees to immediately notify MCO if any encounter data that Provider submitted to MCO for Medicare Members is inaccurate, incomplete, or erroneous, and to cooperate with MCO to correct erroneous encounter data to ensure MCO’s compliance with Medicare laws, rules and regulations and CMS instructions.
K. Certification of Data. Provider recognizes that MCO is required to certify the accuracy,
completeness, and truthfulness of data that CMS requests. Such data include encounter data, payment data, and any other information provided to MCO by its contractors and subcontractors. Provider and its subcontractors, if any, hereby certify that any such data submitted to MCO will be accurate, complete, and truthful. Upon request, Provider shall make such certification in the form and manner prescribed by MCO.
L. Medicare Member Complaints. Provider agrees to cooperate with MCO in resolving any
Medicare Member complaints related to coverage or the provision of Covered Services. MCO will notify Provider as necessary concerning all Medicare Member complaints involving Provider. Provider shall, in accordance with the Provider’s regular procedures, investigate such complaints and respond to MCO in the required time. Provider shall use best efforts to resolve complaints in a fair and equitable manner.
M. Compliance Program and Anti-Fraud Initiatives. Provider shall (and shall cause its
Downstream Entities, if any, to) institute, operate, and maintain an effective compliance program to detect, correct, and prevent the incidence of non-compliance with CMS requirements and the incidence of fraud, waste, and abuse (“FWA”) relating to the operation of the Medicare Plan. Such compliance program shall
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be appropriate to the organization and operations of Provider and Provider’s Downstream Entities and shall include:
(1) written compliance policies and standards of conduct that are comparable to
MCO’s compliance policies, Code of Conduct and articulate the entity’s commitment to comply with federal and state laws, ethical behavior, and compliance program operations. Provider will disseminate such compliance policies, Code of Conduct or comparable versions to Provider’s employees, officers, and Downstream Entities within 90 days of hire/contracting, when updates are made, and annually thereafter;
(2) reporting mechanisms communicated to Provider’s employees and Downstream
Entities for their use in adhering to the expectation that Provider, its employees, and its Downstream Entities report potential non-compliance or FWA issues (internally and to MCO, as applicable) and understand their obligation to report. Provider must publicize the reporting methods to Provider employees and Downstream Entities along with a no-tolerance policy for retaliation or retribution for good-faith reporting;
(3) completion of CMS’s Medicare Learning Network® (MLN) “Medicare Parts C
and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training” by Provider employees, officers, and Downstream Entities initially within ninety (90) days of hire/contracting and at least annually thereafter, unless exempt from such training under relevant CMS regulations;
(4) processes to oversee and ensure that Provider and Provider’s Downstream
Entities maintain compliance with processes to oversee and ensure that: (1) Provider and Provider’s Downstream Entities maintain compliance with CMS compliance program requirements, and (2) Provider’s Downstream Entities perform Medicare Services consistent with this Agreement and the agreement between Provider and such Downstream Entities. Provider’s oversight under this Agreement shall include: (1) imposition of disciplinary actions, as needed, to ensure employee compliance with CMS compliance program requirements, and (2) implementation of corrective actions (up to and including contract termination), as needed, with respect to its Downstream Entities to ensure Downstream Entity compliance with applicable CMS requirements, including the CMS compliance program requirements, this Agreement, and Provider’s contract with the Downstream Entity; and
(5) retention of evidence showing that Provider and Provider’s Downstream Entities
complied with the requirements set forth in this Section. Such evidence must be maintained for at least the period of time specified in Section B.5.F. hereof and shall be made available to MCO and CMS, upon request.
N. Marketing. Consistent with federal laws, regulations, and agency requirements
applicable to the Medicare program, Provider shall not: (1) engage in any marketing or sales activities that could mislead or confuse Medicare Members, or (2) market or advertise non-health care related products to Medicare Members or prospective Medicare Members. Further, Provider shall at all times comply with the then current Medicare Marketing Guidelines.
O. Dual-Eligible Hold Harmless. Provider acknowledges and agrees that Medicare
Members are not responsible for paying to Provider any Copayments, Coinsurance, or Deductibles for Medicare Part A and Part B services (“Cost Sharing Amounts”) when, as applicable, either the State Medicaid plan or MCO (as the State’s managed-care organization) is responsible for such Cost Sharing Amounts. Provider further agrees that it will not collect Cost Sharing Amounts from Medicare Members when, as applicable, either the State Medicaid plan or MCO (as the State’s managed-care organization) is responsible for such Cost Sharing Amounts, and will instead accept the responsible party’s payment for Covered Services as payment in full for Covered Services and applicable Cost Sharing Amounts.
P. Enrollment as Medicare Provider. To the extent that Provider prescribes drugs covered
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under Medicare Part D to Medicare Members who have Medicare prescription drug (“MA-PD”) coverage offered by MCO, Provider agrees to comply with the requirements set forth in 42 C.F.R. § 423.120(c)(6), including without limitation the requirement that Provider be enrolled in Medicare in an approved status in order for its prescriptions to be covered under Medicare Part D.
Q. Home Infusion Drugs. The following provisions shall only apply to Provider if Provider
dispenses to a Medicare Member home infusion drugs that are covered under Medicare Part D and the Medicare Member has MA-PD coverage offered by MCO (“Home Infusion Drug”):
1. With respect to Home Infusion Drugs, MCO will pay clean claims (as defined in 42 C.F.R. § 423.520(b)) submitted by Provider on behalf of Medicare Members within 14 days for electronic claims and within 30 days for claims submitted otherwise. 42 C.F.R. § 423.505(i)(3)(vi).
2. Home Infusion Drugs will be reimbursed (as applicable) in accordance with a
fee schedule, or the third-party pricing source (e.g., Medi-Span) otherwise agreed upon as set forth in this Agreement or Provider’s agreement with MCO’s Pharmacy Benefit Manager (“PBM”). 42 C.F.R. § 423.505(i)(3)(viii)(B).
3. If a prescription drug pricing standard is used for reimbursement of Home
Infusion Drugs, updates to such a standard will occur not less frequently than once every 7 days beginning with an initial update on January 1 of each year, to accurately reflect the market price of acquiring the Home Infusion Drug. 42 CFR § 423.505(i)(3)(viii)(A).
4. In accordance 42 C.F.R.§ 423.120(c)(3), Provider agrees to submit claims for
Home Infusion Drugs to MCO or its PBM whenever the Medicare Member’s ID card is presented or is on file at the Provider, unless the Medicare Member expressly requests that the claim not be submitted to MCO or its PBM.
5. Provider must submit claims for Home Infusion Drugs in real time by means of
point of service claims adjudication systems in compliance with CMS standards. 42 C.F.R. § 423.505(b)(17).
6. Provider must provide Medicare Members with access to the negotiated prices
(as defined in 42 C.F.R. § 423.100) for Home Infusion Drugs to Members. 42 C.F.R. § 423.104(g)(1).
7. Provider must charge/apply the correct cost-sharing amount to the Medicare
Member for Home Infusion Drugs. 42 C.F.R. § 423.104.
8. At the time of purchase by a Medicare Member, Provider must inform the Medicare Member of any differential between the price of the Home Infusion Drug being dispensed and the price of the lowest priced generic version of that Home Infusion Drug available from Provider, unless the Home Infusion Drug being dispensed is the lowest priced generic version of that Home Infusion Drug. 42 C.F.R. § 423.132.
9. Provider agrees to ensure that the professional services and ancillary supplies
necessary for Home Infusion Drugs are in place before dispensing Home Infusion Drugs to a Medicare Member in his/her place of residence. 42 C.F.R. § 423.120(a)(4)(iii).
10. Provider agrees to provide delivery of Home Infusion Drugs within 24 hours of
a Medicare Member’s discharge from an acute setting, or later if so prescribed. 42 C.F.R. § 423.120(a)(4)(iv).
11. Provider shall submit to MCO (not PBM) claims for equipment, supplies, and
professional services associated with Home Infusion Drugs dispensed by Provider to a Medicare
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Member that are covered under Medicare Part C.
R. Non-Covered Services. Provider shall not hold a Member financially responsible for payment of a service not covered under the Member’s Plan (“Non-Covered Service”) unless the Member has received a pre-service organization determination notice of denial from MCO before such services are rendered. Provider acknowledges and agrees that if Provider renders Non-Covered Services to a Member who has not received a pre-service organization determination notice of denial from MCO, the Provider must hold the Member harmless for the Non-Covered Services and cannot charge the Member any amount beyond the normal cost-sharing amounts (i.e., copayments, coinsurance, and/or deductibles). With respect to those Non-Covered Services that are clearly listed as exclusions in the Member’s Evidence of Coverage or other similar Plan document, a pre-service organization determination is not required in order for Provider to hold the Member financially liable for such Non-Covered Services.
6. COMPANY OBLIGATIONS.
A. Fee Schedule. MCO shall arrange for Provider to be compensated for health care services rendered to Medicare Members in accordance with Section B.1 of this Duals Addendum.
B. Prompt Pay. In accordance with 42 C.F.R. § 422.520(a)(1), MCO shall make best efforts
to pay clean claims submitted by Provider for Covered Services provided to Medicare Members within thirty (30) calendar days of receipt. For purposes of this Duals Addendum, the term “clean claim” shall have the meaning assigned in 42 C.F.R. § 422.500.
C. From time to time MCO may designate only certain Providers to take part in the provider
delivery network for a particular product benefit plan(s).
7. GENERAL PROVISIONS.
A. Termination. This Duals Addendum may be terminated on its own without respect to the remainder of the Agreement with or without cause by either Party in accordance with the termination provisions of the underlying Agreement and the Three-Way Contract. This Duals Addendum shall terminate automatically in the event that the underlying Agreement is terminated in accordance with the termination provisions of the Agreement and the Three-Way Contract.
B. Governing Law. This Duals Addendum shall be governed by federal laws, regulations,
and agency requirements applicable to the Medicare program. In the event that changes to the governing laws, regulations, or agency requirements applicable to the Medicare program occur, the new law, regulation, or agency requirement shall supersede to the extent required by any such later required changes.
C. Agreement Otherwise Unmodified. All other terms and provisions of the Agreement not
amended hereby shall remain in full force and effect, without modification. In the event of any inconsistency between the terms of this Duals Addendum and the Agreement, the terms of this Duals Addendum shall govern and control.
D. Survival. All provisions of this Duals Addendum that by their nature should survive
termination of Provider’s provision of Medicare Services under this Agreement or termination of the Agreement as a whole, shall survive termination.
C. Requirements Under the MMAI Three-Way Contract
The Three-Way Contract requires that specific additional terms and conditions be incorporated into the Agreement. As such, Provider shall comply with, and shall cause its downstream entities and related entities to comply with, the requirements set forth in this Section C with respect to the provision of Covered Services to Members dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI, and with respect to the provision of administrative or health-benefit management services/functions (or other functions delegated to Provider) that relate to those Covered Services or to the Three-Way Contract and the MMAI. With respect to the requirements set forth
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in this Section C, any capitalized terms that are used but not defined herein shall have the meanings that are ascribed to them in the Three-Way Contract. Provider’s obligations specifically include, and Provider expressly agrees to comply with, the following:
1. The delegated activities and reporting requirements for which Provider is responsible are
contained in the Agreement. Provider shall ensure that it and its downstream and related entities perform all such delegated activities and reporting requirements in compliance with 42 C.F.R. §§ 422.504, 423.505, 438.6(l), and 438.230(b)(1), as applicable. [Appendix C, ¶ A of Three-Way Contract]
2. HHS, the Comptroller General, the State of Illinois Department of Healthcare and Family Services
(the “Department”), the Department’s Office of Inspector General, the Medicaid Fraud Control Unit of the Illinois State Police, the Illinois Auditor General, and their designees, and other state and federal agencies with monitoring authority related to Medicare and Medicaid, have the right to audit, evaluate, and inspect any books, contracts, computer, or other electronic systems, including medical records and documentation, of Provider and its downstream and related entities, and the foregoing rights to inspect, evaluate, and audit any pertinent information for any particular contract period shall exist for ten years from the final date of the contract period or from the date of completion of any audit, whichever is later. [Appendix C, ¶ B of Three-Way Contract]
3. Provider and its downstream and related entities shall not hold Enrollees liable for payment of any
fees that are the obligation of MCO. [Appendix C, ¶ C.1 of Three-Way Contract]
4. Any services or other activity performed by Provider and/or its downstream and related entities shall be performed in accordance with the MCO’s contractual obligations to CMS and the Department. [Appendix C, ¶ C.2 of Three-Way Contract]
5. MCO shall revoke the delegation activities and reporting requirements or specify other remedies
in instances where CMS, the Department, or the MCO determine that Provider and/or its downstream and related entities have not performed their delegated activities or reporting requirements satisfactorily. [Appendix C, ¶ C.4 of Three-Way Contract]
6. The performance of Provider and its downstream and related entities under the Agreement will be
monitored by MCO on an ongoing basis and MCO may impose corrective action as necessary. [Appendix C, ¶ C.5 of Three-Way Contract]
7. Provider and its downstream and related entities agree to safeguard Enrollee privacy and
confidentiality of Enrollee health records. [Appendix C, ¶ C.6 of Three-Way Contract]
8. Provider and its downstream and related entities must comply with all federal and state laws, regulations, and CMS instructions. [Appendix C, ¶ C.7 of Three-Way Contract]
9. To the extent that Provider and/or its downstream and related entities provide credentialing of
medical providers under the Agreement:
A. The credentials of medical professionals affiliated with the Provider and/or its downstream and related entities will be reviewed by MCO; or
B. The credentialing process will be reviewed and approved by MCO and MCO shall audit
the credentialing process on an ongoing basis. [Appendix C, ¶ D of Three-Way Contract]
10. To the extent that MCO has delegated the selection of providers under the Agreement to Provider
or its downstream and related entities, MCO retains the right to approve, suspend, or terminate that arrangement. [Appendix C, ¶ E of Three-Way Contract]
11. MCO has the right to terminate its contract with Provider with cause upon sixty (60) days’ notice,
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and without cause upon 120 days’ notice, and Provider shall assist with transitioning Enrollees to new providers, including sharing the Enrollee’s medical record and other relevant Enrollee information as directed by the MCO or Enrollee. If a for-cause termination, MCO must have an internal grievance procedure that allows Provider to contest the grounds for the termination prior to the effective date of the termination. [Appendix C, ¶ F of Three-Way Contract]
12. MCO shall provide a written statement to Provider of the reason or reasons for termination for
cause. [Appendix C, ¶ G of Three-Way Contract]
13. MCO is obligated to pay Provider under the terms of the Agreement, which includes a prompt- payment provision that has been developed and agreed to by both MCO and Provider. [Appendix C, ¶ H.1 of Three- Way Contract]
14. Provider and its downstream and related entities shall provide all services under the Agreement in
a Culturally Competent manner to all Enrollees, including those with limited English proficiency or reading skills, and diverse culturally and ethnic backgrounds. [Appendix C, ¶ H.2 of Three-Way Contract]
15. Provider and its downstream and related entities shall abide by all applicable federal and state laws
and regulations regarding confidentiality and disclosure of medical records, or other health and enrollment information. [Appendix C, ¶ H.3 of Three-Way Contract]
16. Provider and its downstream and related entities shall ensure that medical information is released
in accordance with applicable federal or state law, or pursuant to court orders or subpoenas. [Appendix C, ¶ H.4 of Three-Way Contract]
17. Provider and its downstream and related entities shall maintain Enrollee records and information
in an accurate and timely manner. [Appendix C, ¶ H.5 of Three-Way Contract]
18. Provider and its downstream and related entities shall ensure timely access by Enrollees to the records and information that pertain to them. [Appendix C, ¶ H.6 of Three-Way Contract]
19. Provider and its downstream and related entities shall not hold Enrollees liable for Medicare Part
A and B cost sharing, and all Medicare Parts A and B services must be provided at zero cost-sharing to Enrollees. [Appendix C, ¶ H.7 of Three-Way Contract]
20. Provider and its downstream and related entities shall ensure that their EMTALA obligations are
fulfilled as required by law and the Agreement and must not create any conflicts with any hospital actions required to comply with EMTALA. [Appendix C, ¶ H.8 and Section 2.9.9.1 of Three-Way Contract]
21. Provider and its downstream and related entities, including without limitation all primary care
providers, shall not close or otherwise limit acceptance of Enrollees as patients unless the same limitations apply to all commercially insured Enrollees. [Appendix C, ¶ H.9 of Three-Way Contract]
22. MCO shall not refuse to contract or pay Provider for the provision of Covered Services solely
because Provider has in good faith:
(a) Communicated with or advocated on behalf of one or more of the prospective, current, or former patients of Provider or its downstream and related entities regarding the provisions, terms, or requirements of the MCO’s health benefit plans as they relate to the needs of such patients; or
(b) Communicated with one or more of the prospective, current, or former patients of
Provider or its downstream and related entities with respect to the method by which such provider is compensated by the MCO for services provided to the patient.
[Appendix C, ¶ H.10 of Three-Way Contract]
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23. Provider and its downstream and related entities are not required to indemnify MCO for any expenses and liabilities, including, without limitation, judgments, settlements, attorneys’ fees, court costs, and any associated charges, incurred in connection with any claim or action brought against MCO based on MCO’s management decisions, utilization review provisions, or other policies, guidelines, or actions. [Appendix C, ¶ H.11 of Three-Way Contract]
24. Provider and its downstream and related entities shall comply with all MCO’s requirements and
MCO Policies for utilization review, quality management and improvement, credentialing, and the delivery of preventive health services. [Appendix C, ¶ H.12 of Three-Way Contract]
25. MCO shall notify Provider in writing of modifications in payments, modifications in Covered
Services or modifications in MCO’s procedures, documents or requirements, including those associated with utilization review, quality management and improvement, credentialing, and preventive health services, that have a substantial impact on the rights or responsibilities of Provider, and the effective date of the modifications. The notice shall be provided 30 calendar days before the effective date of such modification unless such other date for notice is mutually agreed upon between MCO and Provider or unless such change is mandated by CMS or the Department without 30 calendar days’ prior notice. [Appendix C, ¶ H.13 of Three-Way Contract]
26. Provider must comply with all Enrollee payment restrictions, including balance billing restrictions,
and MCO may revoke or impose other specified remedies against Provider if Provider does not comply with such provisions. [Appendix C, ¶ H.14 of Three-Way Contract]
27. Provider and its downstream and related entities shall not bill Enrollees for charges for Covered
Services other than pharmacy co-payments, if applicable. [Appendix C, ¶ H.15 of Three-Way Contract]
28. No payment shall be made by MCO to Provider, and Provider shall not seek payment from MCO, for a Provider Preventable Condition as defined in 42 C.F.R. § 447.26(b), and Provider shall, as a condition of payment from MCO, comply with reporting requirements on Provider Preventable Conditions as described at 42 C.F.R. § 447.26(d) and as may be specified by MCO and/or the Department. [Section 2.7.3.2 and Appendix C, ¶¶ H.16 and H.17 of Three-Way Contract]
29. To the extent Provider is a Primary Care Physician or a specialty provider, Provider shall ensure
coverage for its practice twenty-four (24) hours a day, seven (7) days a week and have a published after-hours telephone number; voicemail alone after hours is not acceptable. [Section 2.9.2.1 and 2.10.4.1 of Three-Way Contract]
30. MCO shall monitor and ensure that all Utilization Management activities provided by Provider
comply with all provisions of the Three-Way Contract, and Provider and its downstream and related entities shall cooperate with and utilize MCO’s quality assurance program. [Section 2.13.2.1.2.2 and Appendix C, ¶ H.18 of Three-Way Contract]
31. Provider shall not bill Enrollees for missed appointments or refuse to provide services to Enrollees
who have missed appointments. Providers must work with Enrollees and MCO to assist Enrollees in keeping their appointments. [Appendix C, ¶ H.19 of Three-Way Contract]
32. Provider shall not refuse to provide services to an Enrollee because the Enrollee has an
outstanding debt with the Provider from a time prior to the Enrollee becoming a member. [Appendix C, ¶ H.20 of Three-Way Contract]
33. Provider shall comply with all applicable requirements governing physician incentive plans,
including but not limited to such requirements appearing at 42 C.F.R. Parts 417, 422, 434, 438.6(h), and 1003. Contracts or arrangements with First Tier, Downstream and Related Entities shall not include incentive plans that include a specific payment to Provider or its downstream and related entities as an inducement to deny, reduce, delay, or limit specific, Medically Necessary Services, and (a) Provider and/or its downstream and related entities shall not profit from provision of Covered Services that are not Medically Necessary or medically appropriate, and (b) MCO shall not profit from denial or withholding of Covered Services that are Medically Necessary or medically
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appropriate. Nothing herein shall be construed to prohibit contracts that contain incentive plans that involve general payments such as capitation payments or shared-risk agreements that are made with respect to physicians or physician groups or that are made with respect to groups of Enrollees if such agreements, which impose risk on such physicians or physician groups for the costs of medical care, services, and equipment provided or authorized by another physician or health care provider, comply with Paragraph 34 immediately below. [Appendix C, ¶¶ H.14 and I, and Section 5.1.7 of Three-Way Contract]
34. MCO shall not impose a financial risk on Provider or its downstream and related entities for the
costs of medical care, services, or equipment provided or authorized by another Physician or health care provider unless such contract includes specific provisions with respect to the following:
A. Stop-loss protection;
B. Minimum patient population size for the Physician or Physician group; and
C. Identification of the healthcare services for which Physician or Physician group is at risk.
[Appendix C, ¶ J of Three-Way Contract]
35. All contracts or arrangements with First Tier, Downstream and Related Entities for laboratory testing sites that provide services must include an additional provision that such laboratory testing sites must have either a Clinical Laboratory Improvement Amendment (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. [Appendix C, ¶ K of Three-Way Contract]
36. Nothing shall be construed to restrict or limit the rights of MCO to include as providers religious
non-medical providers or to utilize medically based eligibility standards or criteria in deciding provider status for religious nonmedical providers. [Appendix C, ¶ L of Three-Way Contract]
37. Provider shall meet all terms and requirements of the Three-Way Contract that are applicable to
Provider. [Section 2.7.2.2.1 of Three-Way Contract]
38. Provider will collaborate with MCO on documentation systems reporting, communications, policies, and any other matters necessary for any readiness review required under the Three-Way Contract. [Section 2.2.1 of Three-Way Contract]
39. Provider shall collaborate with MCO, as requested and required under the Three-Way Contract, on
activities relating to Care Coordination and the Enrollee Care Plans. [Section 2.5 of Three-Way Contract]
40. As requested and required under the Three-Way Contract, Provider shall actively participate as a member of the Interdisciplinary Care Team, and shall collaborate with the Enrollee and other members of the Interdisciplinary Care Team to perform the functions and tasks that are required of the Interdisciplinary Care Team under the Three-Way Contract. [Section 2.5.2 of Three-Way Contract]
41. Provider must maintain locations that are accessible to Enrollees with disabilities and that are
ADA compliant. [Section 2.8.1.4 of Three-Way Contract]
42. Provider shall be responsive to the linguistic, cultural, ethnic, racial, religious, age, gender and other unique needs of any minority, homeless population, Enrollee with disabilities (both congenital and acquired disabilities), or other special population served by the MCO. [Section 2.7.1.6 of Three-Way Contract]
43. To the extent that Provider is multilingual, Provider shall understand and comply with its
obligations under state or federal law to assist Enrollees with skilled medical interpreters and the resources that are available to assist Provider to meet these obligations. [Section 2.7.1.8 of Three-Way Contract]
44. Provider shall maintain a strong understanding of disability culture and Long Term Supports and
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Services. [Section 2.7.1.14 of Three-Way Contract]
45. To the extent that Provider provides Medicare-covered services, Provider shall be enrolled as a Medicare provider in order to submit claims for reimbursement or otherwise participate in the Medicare program. To the extent that Provider provides Medicaid-covered services, Provider shall be enrolled in the Illinois Medicaid program, if such enrollment is required by the Department’s rules or policy, in order to submit claims for reimbursement or otherwise participate in the Illinois Medicaid program. [Section 2.8.1.2 of Three-Way Contract]
46. If a Provider provides any Emergency Services to an Enrollee, the Provider must promptly notify
the Enrollee’s Primary Care Physician of the Enrollee’s screening and treatment. [Section 2.9.8.1.7 of Three-Way Contract]
47. If any Grievance or Appeal is filed with Provider, Provider must immediately forward it to MCO.
[Section 2.11.1.1 of Three-Way Contract]
48. Provider must comply with the American with Disabilities Act (ADA) (28 C.F.R. § 35.130) and Section 504 of the Rehabilitation Act of 1973 (Section 504) (29 U.S.C. § 794) as outlined in the Three-Way Contract, and must maintain capacity to deliver services in a manner that reasonably accommodates the needs of Enrollees. [Section 2.9.1.6 of Three-Way Contract]
49. Upon MCO’s request, Providers must provide the following information: (a) its name, address,
and telephone number; (b) its areas of special experience, skills and training, including any expertise in treating the MMAI population; (c) its office hours, including the name of any provider site open after 5:00 p.m. (Eastern Time) weekdays and/or open on weekends; (d) its cultural and linguistic capabilities, including languages spoken by the Provider or by any skilled medical interpreter at the Provider’s site; (e) Provider licensing information; (f) whether it is accessible for people with physical disabilities; (g) whether it is accepting new patients; (h) whether it is accessable by public transportation; and (h) any languages other than English spoken by Provider or by skilled medical interpreters at Provider’s site, and whether translation services are available. [Section 2.14.5.2 of Three- Way Contract]
50. As requested and required, Provider must provide any information that CMS and/or the
Department require (a) under the Three-Way Contract related to the performance of MCO’s responsibilities, including non-medical information for the purposes of research and evaluation; (b) to comply with all applicable federal or state laws and regulations; and (c) for external rapid cycle evaluation including program expenditures, service utilization rates, rebalancing from institutional to community settings, Enrollee satisfaction, Enrollee Grievances and Appeals and enrollment/disenrollment rates. [Section 2.16.1 of Three-Way Contract]
51. Collaborate with MCO in the collection and maintenance of all Encounter Data for all Covered
Services that Provider provides to Enrollees, ensuring that all such data can be linked to the Department eligibility data. [Section 2.17 of Three-Way Contract]
52. In connection with the MMAI, Provider shall act in an independent capacity and not as an officer,
employee, or agent of the federal government or the State of Illinois. [Section 5.1.3.1 of Three-Way Contract]
53. Provider shall not have any interest that will conflict, as determined by CMS and the Department, with the performance MCO’s services under the Three-Way Contract, including without limitation any financial, legal, contractual or other business interest in any entity performing enrollment functions for the Department. [Section 5.3.17 of Three-Way Contract]
54. If requested by the State of Illinois in response to a background check of any officer, employee, or
agent of the Provider, the Provider shall immediately reassign any such individual who, in the opinion of the State of Illinois, does not pass the background check. [Section 5.3.21.1 of Three-Way Contract]
55. Provider is prohibited from giving gifts to Department employees, and from giving gifts to, or
accepting gifts from, any person who has a contemporaneous contract with the Department involving duties or obligations related to the Three-Way Contract. [Section 5.3.21.8 of the Three-Way Contract]
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56. As requested by MCO, Provider shall submit disclosures in accordance with 42 C.F.R. § 455 and 42 C.F.R. § 1002.3. [Section 5.1.6 of Three-Way Contract]
57. Provider shall notify MCO immediately if Provider has lost any required license or state or federal
approval, or has been excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, and implementing regulations at 42 C.F.R. Part 1001 et seq. [Sections 2.7.1.3 and 5.3.4 of Three-Way Contract]
58. Provider and its downstream and related entities shall allow MCO to access the medical records of
Enrollees, and such access shall include the right to make and/or obtain a copy (in either electronic or hardcopy form) of such records. [Section 2.13.4.2.3 of Three-Way Contract]
59. If the Provider is discharging an Enrollee from a hospital, Provider must assure that the Enrollee
receives a written notice of explanation called an “Important Message from Medicare About your Rights” regarding the right to appeal the discharge decision from an inpatient hospital admission. [Section 2.12.7.1 of Three-Way Contract]
60. Providers shall offer hours of operation that are no less than the hours of operation offered to
individuals who are not Enrollees. [Section 2.8.6 of Three-Way Contract]
61. Provider must be appropriately and continually licensed or certified, as applicable, pursuant to federal and statement requirements. [Section 2.7.2.2.4 of Three-Way Contract]
62. Provider shall conduct all activities in accordance with the Enrollee rights and protections set forth
under 42 C.F.R. § 438.100, 42 C.F.R. §422 Subpart C, and Appendix B (“Enrollee Rights”) of the Three-Way Contract. [Appendix B of Three-Way Contract]
63. Provider may not reuse or provide other entities access to the CMS or Illinois information
systems, or data obtained from the CMS or Illinois information systems, to support any line of business other than the MMAI for which the MCO contracted with CMS and the State of Illinois. [Appendix F of Three-Way Contract]
64. Provider acknowledges and agrees that compliance with Sections 5.3.22 through 5.3.32 of the
Three-Way Contract and each subsection thereof (collectively, the “Standard Certifications”) is a material requirement and condition of this Agreement during the entire term thereof, including during any renewal periods. By executing the Agreement, Provider certifies compliance with the Standard Certifications in their entirety, and Provider is under a continuing obligation to remain in compliance with, and to report any non-compliance with respect to, the Standard Certifications. Furthermore, Provider shall include the Standard Certifications in any subcontracts or other contracts with downstream entities or related entities that Provider enters into with respect to the provision of Covered Services to Enrollees dually eligible for both Medicare and Medicaid under the Three-Way Contract and the MMAI, including the performance of any activities delegated to Provider in connection with the Three-Way Contract and the MMAI; if the Agreement extends over multiple fiscal years, including the initial term and all renewals, Provider and any such subcontractors, downstream entities, or related entities shall confirm compliance with the Standard Certifications in the manner and format determined by the State of Illinois by the date specified by the State of Illinois, and in no event later than July 1 of each year that the Agreement remains in effect.
If the Parties determine that any Standard Certification is not applicable to the Agreement, such Standard
Certification may be stricken without affecting the remaining Standard Certifications.
As part of each Standard Certification, Provider acknowledges and agrees that if Provider or its subcontractors, downstream entities, or related entities provide false information, or fail to be or remain in compliance with the Standard Certifications, one or more of the following sanctions will apply: (a) the Agreement may be void by operation of law; (b) the State of Illinois may void the Agreement; and (c) the Provider and its subcontractors, downstream entities, or related entities may be subject to one or more of the following: suspension, debarment, denial of payment, civil fine, or criminal penalty. Identifying a sanction or failing to identify a sanction in relation to any of the Standard Certifications does not waive imposition of other sanctions or preclude application of sanctions not specifically identified.
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a. Provider certifies it and its employees will comply with applicable provisions of the
United States Civil Rights Act, Section 504 of the Federal Rehabilitation Act, the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.), and applicable rules in performance of this Agreement.
b. Provider certifies, if applicable, that it is a properly formed and existing legal entity (30
ILCS 500/1.15.80, 20-43); and as applicable has obtained an assumed name certificate from the appropriate authority, or has registered to conduct business in Illinois and is in good standing with the Illinois Secretary of State.
c. Provider certifies it has neither been convicted of bribing or attempting to bribe an officer
or employee of the State of Illinois or any other state, nor made an admission of guilt of such conduct that is a matter of record. 30 ILCS 500/50-5.
d. If Provider employs twenty-five (25) or more employees and the Agreement is worth
more than $5,000, Provider certifies that it will provide a drug free workplace pursuant to the Drug Free Workplace Act (30 ILCS 580).
e. Provider certifies that neither Provider nor any substantially owned affiliate of Provider is
participating or shall participate in an international boycott in violation of the U.S. Export Administration Act of 1979 or the applicable regulations of the U.S. Department of Commerce. This applies to contracts that exceed $10,000 (30 ILCS 582).
f. Provider certifies that it has not been convicted of the offense of bid rigging or bid
rotating or any similar offense of any state or of the United States (720 ILCS 5/33E-3, E-4).
g. Provider certifies that it complies with the Illinois Department of Human Rights Act and rules applicable to public contracts, including equal employment opportunity, refraining from unlawful discrimination, and having written sexual harassment policies (775 ILCS 5/2-105).
h. Provider warrants and certifies that it and, to the best of its knowledge, its subcontractors,
downstream entities, or related entities, have and will comply with Executive Order No. 1 (2007). That Order generally prohibits contractors and subcontractors from hiring the then-serving Illinois Governor’s family members to lobby procurement activities of the State of Illinois, or any other unit of government in Illinois including local governments if that procurement may result in a contract valued at over $25,000. This prohibition also applies to hiring for that same purpose any former State of Illinois employee who had procurement authority at any time during the one-year period preceding the procurement lobbying activity.
i. Provider certifies that it is not currently barred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this transaction by any federal or state department or agency, and is not currently barred or suspended from contracting with the State of Illinois under Section 50-35(f), 50-35(g) or 50-65 of the Illinois Procurement Code, 30 ILCS 500/1-1 et seq. If at any time during the term of this Agreement, Provider becomes barred, suspended, or excluded from participation in this transaction, Provider shall, within thirty (30) days after becoming barred, suspended, or excluded, provide to the Department a written description of each offense causing the exclusion, the date(s) of the offense, the action(s) causing the offense(s), any penalty assessed or sentence imposed, and the date any penalty was paid or sentence complete.
j. Provider certifies that, to the best of its knowledge and belief, no federally appropriated
funds have been paid or will be paid by or on behalf of Provider, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal loan or grant, or the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement. If any funds other than federally appropriated funds have been paid or will be paid
- 40 - Illinois Medicaid RCA (rev. 2.2016)
to any person for influencing or attempting to influence an officer or employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan or cooperative agreement, Provider shall complete and submit Standard Form LLL, “Disclosure Forms to Report Lobbying,” in accordance with its instructions. Such form is to be obtained at Provider’s request from the Department’s Bureau of Fiscal Operations. Provider shall require that the language of this certification be included in the award document for sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this Agreement was executed. Submission of this certification is a prerequisite for making or entering into the transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
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ADDENDUM B — Schedule 1
Medicare Required Provisions
CMS requires that specific terms and conditions be incorporated into the Agreement between a Medicare Advantage Organization or First Tier Entity and a First Tier Entity or Downstream Entity to comply with the Medicare laws, regulations, and CMS instructions, including, but not limited to, the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Pub. L. No. 108-173, 117 Stat. 2066 (“MMA”); and
Except as provided herein, all other provisions of the Agreement between Company (or its Affiliate, as the case may be) and Provider (referred to in this Schedule 1 as “FDR”) not inconsistent herein shall remain in full force and effect. This Amendment shall supersede and replace any inconsistent provisions to such Agreement; to ensure compliance with required CMS provisions, and shall continue concurrently with the term of such Agreement.
NOW, THEREFORE, the parties agree as follows:
A. Definitions:
1. Centers for Medicare and Medicaid Services (“CMS”): the agency within the Department of Health and Human Services that administers the Medicare program.
2. Completion of Audit: completion of audit by the Department of Health and Human Services, the Government
Accountability Office, or their designees of a Medicare Advantage Organization, Medicare Advantage Organization contractor or related entity.
3. Downstream Entity: any party that enters into a written arrangement, acceptable to CMS, with persons or
entities involved with the MA benefit, below the level of the arrangement between an MA organization (or applicant) and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.
4. Final Contract Period: the final term of the contract between CMS and the Medicare Advantage Organization.
5. First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MA organization
or applicant to provide administrative services or health care services for a Medicare eligible individual under the MA program.
6. Medicare Advantage (“MA”): an alternative to the traditional Medicare program in which private plans run by
health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
7. Medicare Advantage Organization (“MA organization”): a public or private entity organized and licensed by a
State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements.
8. Member or Enrollee: a Medicare Advantage eligible individual who has enrolled in or elected coverage through
a Medicare Advantage Organization.
9. Provider: (1) any individual who is engaged in the delivery of health care services in a State and is licensed or certified by the State to engage in that activity in the State; and (2) any entity that is engaged in the delivery of health care services in a State and is licensed or certified to deliver those services if such licensing or certification is required by State law or regulation.
10. Related entity: any entity that is related to the MA organization by common ownership or control and (1)
performs some of the MA organization's management functions under contract or delegation; (2) furnishes
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services to Medicare enrollees under an oral or written agreement; or (3) leases real property or sells materials to the MA organization at a cost of more than $2,500 during a contract period.
B. Required Provisions:
FDR agrees to the following:
1. HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any pertinent information for any particular contract period, including, but not limited to, any books, contracts, computer or other electronic systems (including medical records and documentation of the first tier, downstream, and entities related to CMS’s contract with Company (hereinafter, “MA organization”) through 10 years from the final date of the final contract period of the contract entered into between CMS and the MA organization or from the date of completion of any audit, whichever is later. [42 C.F.R. §§ 422.504(i)(2)(i) and (ii)] and [42 CFR §423.505]
2. HHS, the Comptroller General, or their designees have the right to audit, evaluate, collect, and inspect any
records under paragraph 1 of this amendment directly from any first tier, downstream, or related entity. For records subject to review under paragraph 1, except in exceptional circumstances, CMS will provide notification to the MA organization that a direct request for information has been initiated. [42 C.F.R. §§ 422.504(i)(2)(ii) and (iii)]
3. FDR will comply with the confidentiality and enrollee record accuracy requirements, including: (1)
abiding by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information, (2) ensuring that medical information is released only in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas, (3) maintaining the records and information in an accurate and timely manner, and (4) ensuring timely access by enrollees to the records and information that pertain to them. [42 C.F.R. §§ 422.504(a)(13) and 422.118] and [42 CFR §423.136]
4. Enrollees will not be held liable for payment of any fees that are the legal obligation of the MA
organization. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)] and [42 CFR §423.505(i)(3)(i)]
5. For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for Medicare Part A and B cost sharing when the State is responsible for paying such amounts. Providers will be informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid. FDR may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under title XIX if the individual were not enrolled in such a plan. Providers will: (1) accept the MA plan payment as payment in full, or (2) bill the appropriate State source. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)]
6. Any services or other activity performed in accordance with a contract or written agreement by FDR are
consistent and comply with the MA organization's contractual obligations. [42 C.F.R. § 422.504(i)(3)(iii)] and [42 CFR §423.505(i)(3)(iii)]
7. Contracts or other written agreements between the MA organization and providers or between first tier and
downstream entities must contain a prompt payment provision, the terms of which are developed and agreed to by the contracting parties. The MA organization is obligated to pay contracted providers under the terms of the contract between the MA Organization/Physician and the provider. [42 C.F.R. §§ 422.520(b)(1) and (2)]
8. FDR and any related entity, contractor or subcontractor will comply with all applicable Federal and
Medicare laws, regulations, and CMS instructions. [42 C.F.R. §§ 422.504(i)(4)(v)] and [42 CFR §423.505(i)(4)(iv)]
9. If any of the MA organization’s activities or responsibilities under its contract with CMS are delegated to
- 43 - Illinois Medicaid RCA (rev. 2.2016)
any first tier, downstream and related entity:
(i) The delegated activities and reporting responsibilities are specified as follows:
See delegated activities and reporting responsibilities set forth in the Medicaid Contractor Agreement, dated April 1, 2011 (as amended), and its delegated function addenda.
(ii) CMS and the MA organization reserve the right to revoke the delegation activities and
reporting requirements or to specify other remedies in instances where CMS or the MA organization determine that such parties have not performed satisfactorily.
(iii) The MA organization will monitor the performance of the parties on an ongoing basis.
See the terms of the Medicaid Contractor Agreement, dated April 1, 2011 (as amended), and its delegated function addenda, for specific performance-monitoring provisions.
(iv) The credentials of medical professionals affiliated with the party or parties will be either
reviewed by the MA organization or the credentialing process will be reviewed and approved by the MA organization and the MA organization must audit the credentialing process on an ongoing basis.
See the terms of the Medicaid Contractor Agreement, dated April 1, 2011 (as amended), and its delegated function addenda, for specific credentialing provisions.
(v) If the MA organization delegates the selection of providers, contractors, or subcontractor, the
MA organization retains the right to approve, suspend, or terminate any such arrangement. [42 C.F.R. §§ 422.504(i)(4) and (5)]
In the event of a conflict between the terms and conditions above and the terms of a related agreement, the terms above control.
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