aps contract

8/4/2019 Aps Contract

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INNOVATIVE RESOURCE GROUP, LLCdba APS Healthcare Midwest, LLC

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Exhibit AScope of Work

1. Service Overview

Contractor agrees to provide to the Department of Health Care Services (DHCS) the

services described herein.

The Contractor shall develop, test, implement and maintain a Coordinated CareManagement Program-Serious Mental Illness (CCMP-SMI). Coordinated CareManagement (CCM) services will be provided to Seniors and Persons withDisabilities (SPD) with chronic health conditions and Serious Mental Illnesses (SMI).

The Contractor shall be responsible for, but not limited to, providing the followingservices:

a. Contract Administrationb. Management Information Systems (MIS)

c. Quality Improvement System (QIS)d. Utilization Monitoring (UM)e. Member Services

1) Member Rights2) Marketing3) Scope of Services4) Access and Availability

f. Provider Servicesg. Implementation Plan and Deliverables

2. Service Location

CCM services shall be delivered to members that reside in Kern, Kings, Madera,Stanislaus and Tulare counties. DHCS retains the sole and exclusive right underthis Contract to expand the service location of this Contract beyond Kern, Kings,Madera, Stanislaus and Tulare counties. Any determination to expand the servicelocation of this contract outside of Kern, Kings, Madera, Stanislaus and Tularecounties to any additional counties from which DHCS may identify PotentialMembers and CCM services shall be delivered by Contractor, shall be at the solediscretion of DHCS, and may be based upon an insufficient number of PotentialMembers in Kern, Kings, Madera, Stanislaus and Tulare counties, or for any otherreason.

3. Service Hours

The health advice service will be operated 24 hours a day, 7 days a week. All otherservices shall be provided during normal Contractor working hours, Monday throughFriday, excluding national holidays.


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4. Project Representatives

A. The project representatives during the term of this agreement will be:

Department of Health Care Services

Luis Rico, ChiefTelephone: (916) 449-5240Fax: (916) 552-9244E-mail:[email protected]

Innovative Resource Group, LLCdba APS Healthcare MidwestRichard Surles, Chief Development OfficerTelephone: (800) 305-3720x3119Fax: (914) 288-4605E-mail: [email protected]

B. Direct all inquiries to:

Department of Health Care Services

Systems of Care DivisionAttention: Luis RicoMail Station Code 45171501 Capitol AvenueP.O. Box 997419Sacramento, CA 95899-7419

Telephone: (916) 449-5240Fax: (916) 552-9244E-mail: [email protected]

Innovative Resource Group, LLCdba APS Healthcare Midwest

Attention: Richard Surles44 South Broadway, Suite 1200White Plains, NY 10601

Telephone: (800) 305-3720 x3119Fax: (914) 288-4605E-mail: [email protected]

C. Either party may make changes to the information above by giving written noticeto the other party. Said changes shall not require an amendment to thisagreement.

D. All notices to be given under this Contract will be in writing and will be deemedgiven when mailed to DHCS or the Contractor:

Department of Health Care Services Innovative Resource Group, LLCAttention: Luis Rico dba APS Healthcare, Inc.Mail Station 4517 Attn: Richard Surles1501 Capitol Avenue 44 South Broadway, Suite 1200P.O. Box 997413 White Plains, NY 10601

Sacramento, CA 95899-7419
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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5. Scope of Work Contract Performance

A. Contract Administration

Contractor shall maintain the organizational and administrative capabilities toperform its duties and responsibilities under the Contract. This will include, at aminimum, the following:

. Organization and Staffing

Contractor shall maintain the organization and staffing for implementing andoperating the Contract. Contractor shall ensure the following:

a. Organization has an accountable governing body;

b. Staffing in medical and other health services, and in fiscal and administrativeservices, is sufficient to result in the effective conduct of the organizationsbusiness; and

c. Written procedures for the conduct of the business of the organization, whichprovides effective controls.

2. Medical Oversight

a. Contractor shall ensure that medical decisions, including those bysubcontractors, are not unduly influenced by fiscal and administrativemanagement.

b. Contractor shall maintain a physician as Medical Director, who is licensed inCalifornia but is not required to be located in California. Responsibilities ofthe Medical Director shall include, but not be limited to, the following:

1) Ensuring that medical decisions are rendered by qualified medicalpersonnel;

2) Ensuring that medical decisions are not influenced by fiscal oradministrative management considerations;

3) Ensuring that medical protocols and rules of conduct for medical

personnel are followed;

4) Resolving disputes related to the Member and provider services; and

5) Direct involvement in the implementation of Quality Improvementactivities.

c. Contractor shall report to DHCS any changes in the status of the MedicalDirector within ten (10) calendar days.


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3. Reporting Requirements

Many of the data elements required below may be combined into grouped

reports of related elements. Additionally, the Contractor may use electronicspreadsheets to track and report necessary data elements. All reportsprovided to DHCS must be user friendly (easily viewable and printable) and notcontain excessive amounts of unsolicited data. The Contractor will submit thefollowing reports:

a. Monthly Reports

The Contractor shall send monthly reports to DHCS that include thefollowing information. DHCS must receive these monthly reports by thetenth calendar day of each month.

1) Identification of Potential Members, including but not limited to thelisting provided by DHCS, and the method and date of initial contactwith the Potential Member;

2) Identification of Members enrolled in the CCMP-SMI, or the date thePotential Member opted-out;

3) Identification of Provider/Primary Care Provider (PCP) providing CCMservices to CCMP-SMI Members;

4) Identification of individual Member 30-day assessment, due dates andcompletion dates;

5) Identification of individual Member 60-day Individual Treatment Plan(ITP) deadline date and ITP initiation date;

6) Identification of Members who have been disenrolled, disenrollmentdate and the reasons for disenrollment. (This report is intended to reportdisenrollments after they have occurred. All Contractor requests fordisenrollment must be approved by DHCS through a separate process.See Member Services - Scope of Services - Enrollment/Disenrollmentbelow);

7) Health advice service activity, including the number and type of calls;

8) Identification of Members Care Manager and/or Care Managementteam;

9) Risk level assessment; and

10) Other reports to be determined by DHCS.


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b. Quarterly Reports

The Contractor shall send quarterly reports to DHCS that include the

following information. DHCS must receive these quarterly reports withinthirty (30) calendar days after the end of the operational quarter.

1) Provider training;

2) Quality Improvement activities;

3) Quality Improvement Project;

4) Incidence of sentinel events and mortality; and


c. Semi-Annual Reports

The Contractor shall send semi-annual reports to DHCS that include thefollowing information. DHCS must receive semi-annual reports within sixty(60) calendar days after the end of each 6-month operational period:

1) Member status reports (e.g. progress, participation, education received,referrals made, etc.); and


d. Annual Report

The Contractor shall send annual reports to DHCS that include thefollowing information. DHCS must receive these annual reports withinninety (90) calendar days after the end of each twelve (12) monthoperational period:

1) Quality improvement summary;

2) Contractor operational self-assessment; and


e. Performance Measures

The Contractor is required to provide performance measurement dataon claims-based outcomes, process and clinically-based outcomemeasures, and other non-clinical outcome measures. (See Appendix 4for a list of Potential CCMP-SMI Performance Measures).

1) Contractor will develop measures and provide individual memberlevel data on a minimum of three outcome measures for each


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eligible chronic disease and each eligible serious mental illnesslisted in Provision 5.G.2.c & d below. (Note: A sample of themeasures developed will serve as the basis for the Pay for

Performance Calculation Methodology described in Exhibit B,Attachment I, Provision 9).

2) Only one outcome measure per eligible chronic disease/mentalillness may be a claims-based measure.

3) Contractor will provide a minimum of two (2) laboratory values on atleast three (3) eligible chronic conditions and at least three (3)mental illnesses for a specified percentage of the enrolledpopulation per 12 month operational period.

a. The specified percentage of the enrolled population and

methodology for reporting laboratory values will be agreed on bythe Contractor, the Evaluator, and DHCS. DHCS will have finalapproval of the percentage and reporting methodology whichshall not be unreasonably withheld.

4) The independent evaluator will report on the selected claims-basedmeasures using administrative claims data.

5) Contractor will provide baseline data on all non claims-basedmeasures.

6) Measures will be agreed on by the Contractor, the Evaluator, and

DHCS. DHCS shall have final approval of all measures and approvalshall not be unreasonable withheld.

B. Management Information Systems

1. General Requirements

Contractor shall develop a Management Information System (MIS) on behalf ofthe DHCS and shall have processes that support the interactions betweenFinancial, Member and Provider, Eligibility, Encounter Claims, QualityImprovement, Utilization Monitoring and Report Generation subsystems. Theinteractions of the subsystems must be compatible, efficient and successful.

Contractor shall develop and maintain a MIS that provides, at a minimum:

a. DHCS reporting requirements as specified in Exhibit A, Provision 5.A.3;

b. All CCMP-SMI eligibility data including but not limited to data contained inExhibit A, Provision 5.G.2;

c. Information on Members enrolled in the CCMP-SMI, such as Memberassessments, status, care management activities, and outcomes;


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d. Financial information as specified in Exhibit E, Provision 27; and

e. Utilization data sufficient to identify under or over utilization of medication,

services or durable medical equipment.

2. MIS/Data Correspondence

Upon receipt of written notice by DHCS of any problems related to the submittalof data to DHCS, or any changes or clarifications related to Contractors MISsystem, Contractor shall submit to DHCS a Corrective Action Plan withmeasurable benchmarks within thirty (30) calendar days from the date of thepostmark of DHCS written notice to Contractor. Within thirty (30) calendar daysof DHCS receipt of Contractors Corrective Action Plan, DHCS shall approve theCorrective Action Plan or request revisions. Within fifteen (15) calendar daysafter receipt of a request for revisions to the Corrective Action Plan, Contractor

shall submit a revised Corrective Action Plan for DHCS approval.

3. Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Contractor shall comply with Exhibit G - HIPAA Business Associate Addendumrequirements and all Federal and State regulations promulgated from this Act,as they become effective.

C. Quality Improvement System

1. General Requirements

Contractor shall implement an effective Quality Improvement System (QIS).Contractor shall monitor and evaluate all services delivered to Members toensure contract requirements are met and to evaluate the quality of CCMservices rendered. Contractor shall be accountable to address any neededimprovements in meeting contract requirements, CCMP-SMI goals, andimprovements in quality of CCMP-SMI services regardless of the number ofcontracting and subcontracting layers between the Contractor and Member.This provision does not create a cause of action against the Contractor onbehalf of a CCMP-SMI Member for malpractice committed by a Subcontractor.

2. Written Description

Contractor shall develop and implement a written description of its QIS that shallinclude the following:

a. Organizational commitment to the delivery of quality CCMP-SMI servicesas evidenced by goals and objectives, which are approved by Contractorsgoverning body and periodically evaluated and updated;

b. Quality Improvement Committee meets at least quarterly;


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c. System for provider review of QIS findings, which at a minimum,demonstrates provider and other appropriate professional involvement andincludes provisions for providing feedback to staff and providers regarding

QIS study outcomes;

d. Designates a senior-level management member with the authority andresponsibility for the overall operation of the quality management program;and

e. Activities designed to assure the provision of care management andcoordination of services Including but not limited to:

1) Identification of key indicators and measures of consumer and Memberservice, which may include clinical care, complaint rates, and adverseevents;

2) Action plans to improve or correct identified problems;

3) Mechanisms to communicate the results of such activities to thegoverning body and staff; and

4) Tracking and trending of data related to Member service and health careservices.

3. Delegation of Quality Improvement Activities

a. Contractor is accountable for all quality improvement functions and

responsibilities (e.g. Utilization Monitoring, reports, and outcome measures)that are delegated to Subcontractor(s). If Contractor delegates qualityimprovement functions, Contractor and delegated entity (Subcontractor)shall include in their Subcontract, at a minimum:

1) Quality improvement responsibilities, and specific delegated functionsand activities of the Contractor and Subcontractor;

2) Contractors oversight, monitoring, and evaluation processes andSubcontractors agreement to such processes;

3) Contractors reporting requirements and approval processes. The

agreement shall include Subcontractors responsibility to report findingsand actions taken as a result of the quality improvement activities at leastquarterly; and

4) Contractors action/remedies ifSubcontractors obligations are not met.

b. Contractor shall maintain a system to ensure accountability for delegatedquality improvement activities, that at a minimum:


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1) Evaluates, on an annual basis, the Subcontractors ability to perform thedelegated activities including an initial review to assure that theSubcontractor has the administrative capacity, task, experience, and

budgetary resources to fulfill its responsibilities;

2) Ensures Subcontractor meets standards set forth by Contractor andDHCS; and

3) Includes the continuous monitoring, evaluation and approval of thedelegated functions.

4. Quality Improvement Annual Report

Contractor shall develop a quality improvement report for submission toDHCS on an annual basis. The annual report shall include:

a. A comprehensive assessment of the quality improvement activitiesundertaken and an evaluation of areas of success and neededimprovements in services rendered within the quality improvementprogram, including but not limited to, the collection of aggregate data onutilization; the review of quality of services rendered; performancemeasures as referenced in Exhibit A, Provision 5.A.3.e; andoutcomes/findings from Quality Improvement projects.

b. Copies of all final reports of non-governmental accrediting agencies(e.g. JCAHO, NCQA, URAC) relevant to the Contractors Medi-Cal line ofbusiness, including accreditation status and any deficiencies noted.

Include the corrective action plan developed to address noteddeficiencies.

c. An assessment of subcontractors performance of delegated qualityimprovement activities.

5. Provider Participation

Contractor shall maintain and implement appropriate procedures to keepproviders serving CCMP-SMI Members informed of the written QIS, its activities,and outcomes.

6. Quality Improvement Projects (QIPs)

a. For this contract, Contractor is required to maintain and conduct two QualityImprovement Projects (QIPs) approved by DHCS.

b. Among the two QIPs:

1) One must be clinical (i.e. to improve services or interventions) such asdevelopment of practice guidelines, assessment tools, etc.).


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2) One must be non-clinical (i.e. availability, accessibility or culturalcompetency of services, etc.).

c. Appropriate timelines will be determined based on the nature of theproblem and interventions selected. QI projects will typically last 12-30months; rapid cycle improvement projects are permissible and encouraged.

d. After obtaining DHCS approval, an initial QIP report is to be submitted withinthree months of QIP initiation. Thereafter, QIP reports will be due on aquarterly basis, or according to a timeline agreed upon by the Contractorand DHCS. At a minimum, the Contractor must submit annual QIP reports.

7. Monitoring and Evaluation

DHCS will arrange for an independent assessment/evaluation of the CCMP-SMI.

The measures to be evaluated will include, but not be limited to, costeffectiveness and process and outcome measures for clinical, financial,humanistic, program implementation and plan operation variables. The finallist of measures within each category will be agreed on by the Contractor, DHCSand the independent evaluation contractor. The DHCS will have final approvalof all evaluation measures and approval shall not be unreasonably withheld.The Contractor will cooperate with the independent assessment/evaluationprocess by providing necessary data and furnishing information on programoperations as required by DHCS or the independent evaluator.

D. Utilization Monitoring

Utilization Monitoring (UM) allows an organization to monitor the provision ofservices. Reports and data on service utilization can provide the Contractor withvital information about the delivery of services. Utilization data can determine wherehealth care dollars are being spent, which health care practitioners are providing themost appropriate health care, where Medi-Cal beneficiaries seem to prefer to accesshealth care services, what services are being accessed, and what services may beutilized or delivered inappropriately. The CCMP-SMI emphasizes utilizationmonitoring as an important tool in detecting areas that need improvement.

Contractor shall develop and implement strategies based on utilization monitoringto minimize under/over utilization of emergency department services, acute carehospitalizations, specialist services, medication and other goods and services. At

a minimum, the Contractor will track and trend the following:

1. Utilization per member per month in total, by diagnosis and type of service;

2. Gaps in care (recommended treatment/preventive care versus actualtreatment); and

3. Inappropriate use of medications (per applicable clinical guidelines).


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Contractor will not have the authority to approve, modify or deny services toMembers. All Treatment Authorization Requests (TARs) will be processed throughthe existing Medi-Cal prior authorization system.

E. Member Services Member Rights

1. Member Rights and Responsibilities

Contractor shall develop, implement and maintain written policies that addressMember rights and responsibilities and shall communicate these to its Members.

a. Contractors written policies regarding Member rights shall include thefollowing:

1) To be treated with respect, giving due consideration to the Members

right to privacy and the need to maintain confidentiality of the Membersmedical information;

2) DHCS approved policy for resolving disputes;

3) To be provided with information about the organization and its services;

4) To receive oral interpretation services for identified threshold languagesas listed in Appendix 1-Glossary;

5) To have access to, and when legally appropriate, receive copies of,amend or correct their Member record;

6) To disenroll at any time;

7) To receive written materials in alternative formats, including thresholdlanguage, Braille, large size print, and audio format within fourteen (14)days of request; and

8) To be free from any form of restraint or seclusion used as a means ofcoercion, discipline, convenience, or retaliation.

b. Contractors written policy regarding Member responsibilities shall include,but not limited to, the following:

1) Providing accurate information to staff;

2) Treating staff with respect;

3) Cooperating with care management processes;

4) Participating in the development and the implementation of their ITP;

5) Cooperating with their health care providers; and


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6) Cooperating with the process to resolve member disputes.

c. Contractor shall develop, implement and maintain policies and procedures toensure the Members right to confidentiality of medical information.

1) Contractor shall develop, implement and maintain procedures that guardagainst disclosure of confidential information to unauthorized persons.

2) Contractor shall inform Members of their right to confidentiality andContractor shall obtain Members consent prior to release of confidentialinformation, unless such authorization is not required.

d. Contractor shall maintain the capability to provide Member services toCCMP-SMI Members through sufficient assigned and knowledgeable staff.

e. Contractor shall ensure Member services staff is trained and knowledgeableon all contractually required Member service functions including, policies,procedures, and scope of benefits of this Contract.

f. Contractor shall provide all new CCMP-SMI Members with a written MemberServices Guide. In addition, the Contractor shall provide Potential Memberswith a written Member Services Guide upon request.

1) Contractor shall distribute the Member information no later than seven (7)calendar days after the effective date of the Members Enrollment.Contractor shall revise this information, at least annually, and distribute it

annually to each Member.

2) Contractor shall ensure that all written Member information is provided toMembers at a sixth grade reading level or as determined appropriate byexisting Medi-Cal standards.

3) The written member informing materials shall be translated into theidentified threshold languages upon request by the Member or PotentialMember (Provision H - Member Services, Access and Availability,Linguistic Services).

4) The written member informing materials shall be provided in alternative

formats, threshold languages, including Braille, large size print, and audioformat, within fourteen (14) days of request.

g. Contractor shall develop and provide each Member a Member ServicesGuide that constitutes a fair disclosure of the provisions of the coveredCCMP-SMI services. The Member Services Guide shall be submitted toDHCS for review and subsequent approval prior to distribution to Members.The Member Services Guide shall include the following information:


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1) Description of the CCMP-SMI covered services and benefits and how toaccess them;

2) The importance of establishing a medical home and information on howto contact the Contractor for assistance in this process;

3) Information explaining the importance and value of scheduling andkeeping appointments;

4) Procedures for obtaining emergency health care;

5) Procedures for obtaining any transportation services available through theMedi-Cal program, and how to obtain such services. Include adescription of both medical and non-medical transportation services andthe conditions under which non-medical transportation is available;

6) The causes for which a Member shall lose entitlement to receive servicesunder this Contract as stipulated in Provision G - Member Services Scope of Services, Enrollment/Disenrollment;

7) Procedures for Disenrollment, including an explanation of the Membersright to disenroll without cause at any time;

8) Information on the availability of, and procedures for obtaining, services atFederally Qualified Health Clinics (FQHC) and Rural Health Clinics(RHC); and

9) Any other information determined by DHCS to be essential for the properreceipt of CCMP-SMI services.

h. Contractor shall develop and provide each Member a Provider Directory withinformation on Providers/Specialists currently providing services to Medi-Calbeneficiaries in the Contract area. The Provider Directory shall be updatedannually and submitted to DHCS both electronically and in hard copy forreview and subsequent approval prior to distribution to Members. TheProvider Directory shall include the following information:

1) Name of provider;

2) Professional license number;

3) Medi-Cal identification and/or National Provider Identifier (NPI) number;

4) Group name: Name of physician group affiliation or if Physician isindependent;

5) Type of service as determined by board certification and eligibility;

6) Hospital at which the Physician has admitting staff privileges;


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7) Professional address of the physician;

8) Languages other than English spoken at the office;

9) Hours of operation and hours that the Physician is physically at thislocation;

10) Whether the practice is open or closed to accepting Medi-Cal FFSclients;

11) Number of full-time equivalent non-physician medical practitionersunder the supervision of the Physician; and

12) Areas of accessibility for CCMP-SMI Members with disabilities and

chronic conditions including:

a) Building walkway/accessb) Parkingc) Reception/waiting aread) Exam roome) Restroomsf) Accessible scalesg) Exam tableh) Auxiliary aides and servicesi) Public transportation access

2. Members Records

Contractor shall develop, implement and maintain written procedurespertaining to Members records that address the following areas:

a. Collection, processing, maintenance, storage, retrieval, identification,and distribution;

b. Ensuring that Members records are protected and confidential inaccordance with all Federal and State laws;

c. Release of information; and

d. Ensuring the maintenance of Members records in a legible, current,detailed, organized and comprehensive manner (records may beelectronic or paper copy).


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F. Member Services - Marketing

1. Marketing Plan

Contractor shall develop a marketing plan as specified below. The marketingplan shall be specific to the CCMP-SMI only. Contractor shall implement andmaintain the marketing plan only after approval from DHCS. Contractor shallensure that the marketing plan, procedures, and materials are accurate and donot mislead, confuse, or defraud.

Contractor shall submit a marketing plan to DHCS for review and approval on anannual basis. The marketing plan, whether new, revised, or updated, shalldescribe the Contractors current marketing procedures, activities, and methods.No marketing activity shall occur until the marketing plan has been approved byDHCS; approvals will not be unnecessarily withheld.

The marketing plan shall have a table of contents section that divides themarketing plan into chapters and sections. Each page shall be dated andnumbered so chapters, sections, or pages when revised, can be easily identifiedand replaced with revised submissions.

Contractors marketing plan shall contain the following items and exhibits:

a. Mission Statement or Statement of Purpose for the marketing plan;

b. Organizational chart and narrative description;

The organizational chart shall include the marketing directors name, address,telephone and facsimile number and key staff positions.

The description shall explain how the Contractors internal marketingdepartment operates, identifying key staff positions, roles and responsibilities,and reporting relationships.

c. Marketing Locations;

All sites for proposed marketing activities such as annual health fairs, andcommunity events, in which the Contractor proposes to participate, shall belisted.

d. Marketing Activities;

All marketing methods and activities Contractor expects to use, or participatein, shall be described.

Contractor shall include a letter or other document that verifies cooperation oragreement between the Contractor and an organization to undertake amarketing activity together and certify or otherwise demonstrate thatpermission for use of the marketing activity/event site has been granted.


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e. Marketing Materials;

Copies of all marketing materials the Contractor will use for both English andnon-English speaking populations shall be included; and

f. Marketing Distribution Methods

A description of the methods the Contractor will use for distributing marketingmaterials shall be included.

2. Miscellaneous

DHCS reserves the right to review, approve and/or deny all marketing activities.DHCS approvals shall not be unreasonably withheld. In addition, DHCS

reserves the right to request additional documentation as needed to assess theContractors marketing program.

G. Member Services - Scope of Services

Contractor shall provide or arrange for all CCMP-SMI covered services to CCMP-SMI Members. Contractor will develop policies and procedures to provide CCMP-SMI services which include outreach and assessment, enrollment/disenrollment,care management, health advice service, and member education. Contractor willassist Members with referrals to appropriate medical, mental health, chemicaldependency service providers, and other social services to meet needs identified inassessment. The Contractor will allow DHCS, upon request, to review all

programming logic and algorithms used in the provision of Member Services.

1. Outreach and Assessment

a. Outreach

Contractor will develop policies and procedures for outreach to Members,providers and community resources regarding program information andoperation.

b. Assessment

Members enrolled in the CCMP-SMI must be assessed initially andperiodically, not less than semi-annually, for information about their medical,mental and social condition including, but not limited to: comorbidities, historyof substance abuse, support system, risk level, readiness to participate,special needs; and social, cultural, educational and economic issues. TheContractor will be responsible for developing the assessment tool(s). Theassessment tool(s) and any subsequent changes to it must be approved bythe DHCS and approval shall not be unreasonable withheld. Theassessment shall form the basis for developing an Individual Treatment Plan(ITP) and determine the type and intensity of interventions that are


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appropriate. The Member Assessment will be completed within thirty (30)days of enrollment, and updated at periodic intervals, not less than semi-annually, based on risk level and/or change in health status. Assessment

information may be compiled from various sources, including but not limitedto: telephone contact, claims data, medical record review or surveymethodology, but shall not be obtained through the provision of face-to-facedirect clinical medical services from the Contractor.

2. Enrollment/Disenrollment

DHCS will supply the Contractor with an initial list and, during the programoperations phase, with monthly lists, of potential Members. The Contractor shalldevelop an introductory letter and notify, by mail, all potential Members of theireligibility for CCMP-SMI. The DHCS approved letter shall be the initial contact tothe Potential Member. If a potential Member chooses not to be enrolled, they will

have thirty (30) days from the postmarked date on the letter sent by theContractor to opt-out of the program. In addition to the initial contact letter, theContractor must document three (3) attempts to contact all Potential Members onthe lists provided by DHCS with information regarding CCMP-SMI benefits,services and enrollment/disenrollment procedures. At the beginning of the firstmonth following the end of the initial thirty (30) day opt-out period, PotentialMembers who have not opted-out will be enrolled as CCMP-SMI Members.

The Contractor shall enroll a minimum of five hundred (500) CCMP-SMIMembers to ensure that there is a statistically valid sample size to evaluateprogram effectiveness. The total maximum enrollment allowed will bedetermined by the annual CCMP-SMI funding available and the agreed per

member per month (pmpm) administrative fee.

The Contractor will provide CCM services to those persons who meet all of thefollowing requirements:

a. Are Medi-Cal eligible;b. Are 21 years of age or older; andc. Have a primary or secondary diagnosis of:

1) Cancer;2) Cerebrovascular Disease (CVD);3) Congestive heart failure (CHF);

4) Coronary artery disease (CAD);5) Diabetes mellitus (Diabetes);6) Asthma;7) Chronic obstructive pulmonary disease (COPD);8) Hypertension (HTN);9) Arthritis;10) Obesity;11) Substance Abuse (in the presence of at least one chronic disease listed

above);


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d. Additionally, Seniors and Persons with Disabilities with a chronic conditionlisted above must also have at least one claim in a thirty (30) month period forone of the following serious mental illnesses:

1) Depression2) Bipolar Disorder3) Schizophrenia4) Dementia5) Delusional Disorder6) Nonorganic psychoses7) Anxiety, Dissociative and Somatoform disorder

e. All Medi-Cal beneficiaries receiving full scope Medi-Cal benefits without ashare of cost requirement who meet the qualifications noted above will beconsidered a Potential Member for the CCMP-SMI, except those who:

1) Have restricted/emergency only Medi-Cal;2) Are Medicare eligible;3) Have other insurance that provides comparable CCMP-SMI services

(e.g., Medi-Cal Managed Care);4) Reside in nursing facilities (NF); (in the most recent sic (6) months prior to

enrollment);5) Reside in all levels of Intermediate Care Facilities for the Developmentally

Disabled (ICF/DD) in the most recent 6 months prior to enrollment;6) Have a Medi-Cal eligibility period that is only retroactive;7) Participate in Medicaid waiver programs, including Home and Community

Based, Freedom of Choice and Research and Demonstration waivers;

8) Are enrolled in a hospice program: or9) Have an HIV diagnosis on a Medi-Cal claim since June 1, 2005

f. As part of the enrollment process noted below, DHCS will screen out Medi-Cal beneficiaries who are not eligible for the program by generating a list ofPotential Members according to the actual number of Members will be lessthan the number of Potential Members that opt-out of the CCMP-SMI andother data irregularities that are not within the control of DHCS. Referrals tothe CCMP-SMI from other sources such as self, caregiver, family member,guardian or provider must be approved by DHCS prior to enrollment by thecontractor.

g. The minimum number of Members that will be enrolled in the CCMP-SMI arebased on the quotas as described in provision G.2 above. The maximumnumber of Members enrolled in the CCMP-SMI will be limited by theavailability of funding. If membership exceeds CCMP-SMI availability, DHCSwill develop and implement a process for an enrollment waiting list.

h. A Member who, during the time of CCMP-SMI membership, enters a nursingfacility for a short-term stay of thirty (30) days or less will not be disenrolledexcept at the Members request.


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i. The Contractor shall complete a Member Assessment within thirty (30) daysfrom the date of enrollment. Through the Member assessment, theContractor shall determine the Members health status and include

confirmation that the Member is qualified for the program (e.g. diagnosed withone of the identified disease conditions). If the Contractor determines thatthe Member is not medically qualified for the program, as noted above, theContractor shall coordinate disenrollment with the Contract Administrator.DHCS shall retain control of disenrollment from the CCMP-SMI.

j. Within seven (7) business days of receiving a request for disenrollment of aMember or Potential Member from the Contractor or beneficiary, DHCS willmake a determination and notify the Contractor. Subsequently, theContractor shall notify the Member or Potential Member within seven (7)business days of the disenrollment or denial of a request for enrollment with aNotice containing, at a minimum, the following information:

1) Action taken by the Contractor; and

2) Reason for the action taken.

k. Members will have the option to end their enrollment each month. To requestdisenrollment, Members shall notify the Contractor verbally or in writing. TheContractor shall notify DHCS within two (2) business days of the Membersrequest. Disenrollment will occur on the first day of the month following themonth the request was made. Former Members who disenrolled voluntarilymay reenroll at any time by making a verbal or written request to theContractor. Reenrollment will take place on the first day of the month

following the month the reenrollment request is made.

3. Care Management

The Contractor will adopt standards to improve the health of Members byproviding CCMP-SMI services based on an Individualized Treatment Plan (ITP)that utilizes evidence-based practice guidelines and includes promotingcollaborative relationships with providers, providing Member and Providereducation, and employing reporting and feedback loops for decision making withProviders and Members.

The Contractor shall assign a Care Manager to each Member to oversee and

coordinate CCM activities that include, but are not limited to the following:

a. Development and implementation of interventions for the management ofserious mental illnesses including chronic illness and disability;

b. Development and implementation of interventions for end-of-life assessmentand care to facilitate death with dignity in an appropriate setting of theMembers choice;


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c. Development and implementation of interventions to coordinate Clinical andsocial services;

d. Medication management The Contractor shall develop and implementpolicies and procedures for the following elements:

1) Medication profiling;

2) Medication monitoring;

3) Feedback to Provider/PCP and/or pharmacist; and

4) Member and Provider education.

e. Development of an ITP - Based on the Member assessment, the Contractor

shall assure and coordinate the development of the Individual Treatment Plan(ITP) to be completed and in place within sixty (60) days of enrollment. TheMember or the Members designee, the Provider/PCP and Care Managershould be actively involved in the development and periodic review of theITP;

1) The ITP must include specific provisions for periodic (not less than semi-annual) review and updates to the plan as appropriate. Intervals ofperiodic review and ITP updates should be established based on theseverity of the Members condition.

2) Participants of the review should include, but not be limited to, the

following:

a) Member;

b) Care Manager;

c) Provider/PCP; and

d) Representatives providing services to the Member as identified in theITP (e.g. nutritionist or psychiatrist).

3) The ITP shall take into account:

a) Clinical history, including comorbidities;b) Health status and risk for secondary disabilities or complications;c) Risk level;d) Age;e) Diagnosis/diagnoses;f) Functional and/or cognitive status;g) Mental health;h) Nutrition and weight management;i) Language/comprehension barriers;


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j) Lifestyle issues;k) Cultural/linguistic needs, preference or limitations;l) Level of intensity of care management;

m) Immediate service needs;n) Barriers to care;o) Use of prior authorized services;p) Follow-up schedule;q) Family members/caregiver/facilitator resources and contact

information (if appropriate);r) Local community resources;s) Psychosocial support resources;t) Access/availability of needed medical equipment/accessible medical

equipment;u) Self-management skills;v) Assessment of progress, including input from family if appropriate;

w) Accommodation needs (e.g. appointment time), alternative formats(e.g. Braille, large print, disks, audio, electronic) and auxiliary aids andservices;

x) Program, Member and caregiver goals; andy) Evidenced-based clinical guidelines as available.

f. Coordination/Continuity of Care Contractor shall develop and implementpolicies and procedures related to establishing relationships, developingreferral processes, and sharing information with the Provider/PCP, dischargeplanners, facility staff, Specialists, and State or Community agencies toenable Members to access needed services and ensure continuity of care.The Contractor will ensure continuity of care in collaboration with the

Provider/PCP by:

1) Coordinating care so that an ongoing course of treatment is notinterrupted or delayed due to the change in new providers;

2) Assisting with the transfer of medical record information to new providersin a timely fashion;

3) Assisting with development and implementation of a patient/diseaseregistry capable of being shared with other providers;

4) Monitoring the referral and follow-up of Members in need of specialty care

and routine health care services;

5) Documentation of referral and follow-up services in Members record

6) Documentation in Members record of emergency medical encounterswith the appropriate follow-up as medically indicated;

7) Documentation and follow-up in Members record of planned health careservices; and


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8) Assigning a Care Manager or Care Management team to each Member.

g. The Contractor will establish and make available lines of communication to

allow interaction between the Contractor, Member, and the Provider/PCP;

h. Staffing - at a minimum, the Care Manager will be a licensed registered nurseor other healthcare professional as defined in Section 4999.2 of the CaliforniaBusiness and Professions Code. The Contractor shall also employ theservices of a licensed psychiatrist, psychologist, or licensed/certified mentalhealth specialist, as needed, to address the behavioral and/or mental healthconcerns of the Member. All health care personnel providing services toCCMP-SMI Members must be licensed to practice in California. Staff caseloads shall not exceed current industry standards for disease or caremanagement organizations;

i. Development and implementation of interventions for crisis management;

j. Member Advocacy The ITP shall be developed and implemented to beMember-centered. The Contractor shall advocate on behalf of the member,as necessary, to ensure optimal care for the Member; and

k. Collaboration with other disease and/or care management programs toensure services provided to Members are complementary and not duplicative(e.g. California Mental Health Care Management Program [CalMEND]).

4. Health Advice Service

The Contractor must offer a toll-free telephonic health advice service staffed byhealth care professionals, as defined in California Business and ProfessionsCode Section 4999.2. The service must be operated twenty four (24) hours perday, seven days a week. Operators of the advice service will provide generaland personalized health care information. The advice service will also provideeducation and assistance for CCMP-SMI Members and/or their caregivers. Thisline must be operated in accordance with current managed care program rulesfor comparable advice services, including provisions for interpreter services(Business and Professions Code Section 4999.2 and 4999.7 and Section 1348.8of the Health and Safety Code).

The Contractor must develop and implement a timely method of communicating

the Member telephone contact information with the Members care manager andensure the advice service is operated in an efficient and effective manner.

5. Member Education

a. Contractor shall implement and maintain a health education system thatincludes programs, services, functions, and resources necessary to providehealth education, health promotion and patient education for all Members.


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1) Fully translated written informational materials, including but notlimited to the Member Service Guide, enrollee information, welcomepackets, marketing information, and form letters. Contractor shall

provide translated written informing materials to all non-Englishspeaking or LEP members that speak the identified thresholdlanguage (See Glossary Threshold Language), upon request;

2) Referrals to culturally and linguistically appropriate community serviceprograms;

3) Telecommunications Device for the Deaf (TDD); and

4) Relay service (TTY/711) for persons with speech disabilities.

2. Assist Members to resolve access and disability competency issues

3. Identify areas of provider accessibility for Members with disabilities andchronic conditions including:

a. Building walkway/access;

b. Parking;

c. Reception/waiting area;

d. Exam room;

e. Restrooms;

f. Accessible scales;

g. Exam table;

h. Auxiliary aides and services; and

i. Public transportation access.

4. Changes in Availability or Location of DM Services

Contractor shall provide notification to DHCS sixty (60) calendar days prior tomaking any substantial change in the availability or location of services to beprovided under this Contract. In the event of an emergency or otherunforeseeable circumstance, Contractor shall provide notice of theemergency or other unforeseeable circumstance to DHCS as soon aspossible.


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I. Provider Services

1. Provider Education

Contractor shall provide education and training to Provider/PCP to include, butnot be limited to, the following:

a. Information on all Member rights, Member services, and the right to activelyparticipate in health care decisions;

b. Use of evidence-based practice guidelines;

c. Resource tools developed by the Contractor to facilitate the use of evidence-based practice guidelines by the Provider/PCP;

d. Evaluation and appropriate treatment or referral of mental health issues;

e. The Medi-Cal Treatment Authorization Request (TAR) process;

f. Identification and utilization of community resources; and

g. Disability cultural competency and sensitivity training, including informationabout:

1) Various types of chronic conditions and disabilities prevalent amongMedi-Cal beneficiaries;

2) Awareness of personal prejudices;

3) Legal obligations to comply with the Americans with Disabilities Act(ADA);

4) Scope of benefits, including how to refer people to services covered byother state agencies;

5) Definitions and concepts such as communication access, medicalequipment access, physical access, and access to programs; and

6) The types of barriers that adults with physical, sensory, communicationdisabilities, developmental or mental health needs face in the health carearena and the resulting access and accommodation needs.

2. Provider Feedback

Contractor shall develop and implement system(s), which will provideinformation to the Provider/PCP relating to Members adherence to the ITP.Contractor shall employ feedback techniques to the Provider/PCP to improvethe quality and appropriateness of the care provided to the Member.

J. Implementation Plan and Deliverables

The Implementation Plan and Deliverables section describes DHCS requirementsfor specific deliverables, activities, and timeframes that the Contractor mustcomplete during the Implementation Period before beginning operations.


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Deliverables are those policies and procedures necessary for the conduct ofbusiness including but not limited to those listed in Appendix 5, Summary ofReadiness Review Submissions.

Once the Contract is awarded, the Contractor has thirty (30) calendar days afterthe contract effective date to submit a Workplan for each region/county thatdescribes in detail how and when the Contractor will complete and submit thedeliverables, including but not limited to those listed in Appendix 5, Summary ofReadiness Review Submissions, to DHCS. The Contractors Workplan(s) willinclude a timetable to accomplish the activities to assure timely start-up ofoperations and contingency plan(s) in the event of implementation delays.

The Contractors workplan(s) will identify all of the deliverables, milestones, andtimeframes to achieve an orderly sequence of events that will lead to compliancewith all contract requirements. DHCS will review and approve each workplan(s).

However, Contractor shall not delay the submission of deliverables required in theworkplan(s) while waiting for DHCS approval of previously submitted deliverablesrequired by the workplan(s). Contractor will continue to submit deliverables basedon the milestones and timeframes set forth in the approved DHCS workplan(s). Inthe event the Contractor fails to submit all deliverables in accordance with themilestones and timeframes in the approved DHCS workplan(s), DHCS may imposeLiquidated Damages in accordance with Exhibit E - Additional Provisions, Section20 Liquidated Damages Provisions.

The Implementation Period begins with the contract effective date and extends tothe beginning of the Operations Period (approximately 4 months after the effectivedate of the Contract). The Operations Period is the period of time beginning with

the effective date of the first month of operations and continues through the lastmonth of services to the Members. Phaseout requirements are identified in ExhibitE, Additional Provisions, Provision 18, Phaseout Requirements.

Upon successful completion of the Implementation Plan and Deliverables sectionrequirements and Readiness Review Submissions, DHCS will authorize, in writing,that the Contractor may begin the Operation Period.

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