HomeMy WebLinkAboutMINUTES - 01111994 - 1.48 ..ski 1 , L �
y
TO: BOARD OF SUPERVISORS
FROM: Mark Finucane, Health Services Director 01A ' Contra
By: Elizabeth A. Spooner, Contracts Administrator (Coda
DATE: December 28, 1993 Oiocounty
SUBJECT: Approval of Standard Agreement #29-609-41 with the State
Department of Health Services
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Chair, Board of Supervisors, to execute on behalf of the
County, Standard Agreement #29-609-41 (State #93-18608) with the State Department
of Health Services, for the period from January 1, 1994 through December 31, 1995,
for prepaid health services for Medi-Cal beneficiaries with maximum payable amounts
as set forth below. The payment limits for FY 1994-95 and FY 1995-96 are subject
to future appropriations by the State legislature.
Fiscal Year Payment Limit
1993-94 $ 8,638,000
1994-95 16,265,808
1995-96 (6 months) 8.132.904
Total: $33,036,712
II. FINANCIAL IMPACT:
Approval of this contract by the State will result in a maximum payable amount of
$8,638,000 for FY 1993-94, which has been appropriated by the State. The payment
limits for subsequent fiscal years reflect a maximum allocation should the Health
Plan reach full enrollment. The $8,132,904 for fiscal year 1995-96 covers the six-
month period from July 1, 1995 through December 31, 1995. The net effect on
revenues under this Contract is dependent upon Health Plan enrollment levels.
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
On December 13, 1988, the Board of Supervisors approved Standard Agreement #29-609-
35 with the State Department of Health Services, for prepaid health services for
Medi-Cal beneficiaries, for the period from January 1, 1989 through December 31,
1993. Subsequent amendments have been approved by the Board, the most recent on
June 15, 1993. Standard Agreement #29-609-41 continues prepaid health services for
Medi-Cal beneficiaries through December 31, 1995.
The Board Chair should sign ten copies of the agreement. Nine signed copies of the
agreement and four sealed copies of this Board Order should be returned to the
Contracts and Grants Unit for submission to the State Department of Health Services.
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMM
�DA ION OF BOARD CrOMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF HOARD ON APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
UNANIMOUS (ABSENT _ ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
Contact: Milt Camhi (313-5604)
CC: Health Services (Contracts) ATTESTED �L
Auditor-Controller (Claims) -
State Department of Health Services II Batchelor, er of the Board of
suparyints and 6Qun1y Admin'►straty
�
M382/7-83
BY ' DEPUTY
STdT6�
STANJAHL)AGREEMENT- ATTORNEY�E THE RAL
CONTRACT NUMBER AM.NO.
STm.z(REv.s-9i) 93-18608
TAXPAYERS FEDERAL EMPLOYER IDENTIFICATION NUMBER
1st January 94-6000509
THIS AGREEMENT,made and entered into this day of , 1944_
in the State of California,by and between State of Califomia,.through its duly elected or appointed,qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of LIValth Serv'ces ,hereafter called the State,and
CONTRACTOR'S NAME
The County of Contra Costa M JL ,hereafter called the Contractor.
WITNESSETH: That the Contractor for and in consideration of the covenants,conditions,agreements,and stipulations of the State hereinafter expressed,
does hereby agree to furnish to the State services and materials as follows: (Set forth service to be rendered by Contractor,amount to be paid Contractor,
time for performance or completion,and attach plans and specifications,if any.)
ARTICLE I - PREAMBLE
This contract is entered into under the provisions of the Waxman-Duffy Prepaid Health Plan
Act, Section 14200, et. seq., Welfare and Institutions (W&I) Code.
The Contractor is licensed with the State Department of Corporations under the provisions of
the Knox-Keene Health Care Service Plan Act of 1975.
WHEREAS, it is in the best interest of all parties to renew this contract,
NOW THEREFORE, the contract is renewed as set forth under Article IV of the contract, and
is entered as follows:
CONTINUED ON 52 SHEETS,EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
.The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF,this agreement has been executed by the parties hereto,upon the date first above written.
STATE OF CALIFORNIA CONTRACTOR
AGENCY - CONTRACTOR(11 ther th an individual,state whether a corporation,partnership,etc.)
De
BY(AUTHORIZED SIGNATURE) "NINNAME
SIG )
D
PRINTED NAME OF PERSON SIGNING AND TITLE OF PERSON SIGNING
Edward E. Stahlber
TITLE ADDRESS
Chief Progr Suo rt Branch b51 Pine Street, Martinez, CA 94553 {
AMOUNT ENCUMBERED BY THIS PROGRAMICATEGORY(CODE AND TITLE) FUND TITLE Health Department of General Services
DOCUMENT Local Ast.Sect, 14147 W7I Code Care Deposit use only
$8,638,00' 0 (OPTIONAL USE).
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT
Federal Catalog No. 93778 4260-101-001 & 890
ITEM CHAPTER STATUTE FISCAL YEAR
$ -0- 4260-601-92 55 1993 1993-94
TOTAL AMOUNT ENCUMBERED TO
DATE OBJECT OF EXPENDITURE(CODE AND TITLE)
$ 8,638,000 N/A
I hereby certify upon my own personal knowledge that budgeted funds I T.B.A.NO.
are available for the period and purpose of the expenditure stated above_
SIGNATURE OF ACCOUNTING OFFICER DATE
D
CONTRACTOR STATE AGENCY D DEPT.OF GEN.SER. ❑ CONTROLLER
i
i
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD.2(REV. 5-91) (REVERSE)
1. The Contractor agrees to indemnify,defend and save harmless the State,its officers,agents and employees
from any, and all claims and losses accruing or resulting to any and all contractors, subcontractors,
materialmen,laborers and any other person,firm or corporation furnishing or supplying work services,
materials or supplies;in conn`ection with theTperformance of this contract,and from any and all claims and
losses accruing or resulting to any person,firm or corporation.who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor,and the agents and employees of Contractor,in the performance of the agreement,shall
act in an independent capacity and not as officers or employees or agents of State of California.
3.The State may terminate this agreement and be relieved of the payment of any consideration to Contractor
should Contractor fail to perform the covenants herein contained at the time and in the manner herein
provided. In the event of such termination the State may proceed with the work in any manner deemed
proper by the State. The cost to the State shall be deducted from any sum due the Contractor under this
agreement,and the balance,if any,shall be paid the Contractor upon demand.
4. Without the written consent of the State,this agreement is not assignable by Contractor either in whole
or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be valid unless made in writing and signed by
the parties hereto,and no oral understanding or agreement not incorporated herein,shall be binding on
any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in compensation for all of
Contractor's expenses incurred in the performance hereof, including travel and per diem, unless
otherwise expressly so provided.
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Article II
ARTICLE II -- DEFINITIONS
As used in this contract, unless otherwise expressly provided or the context otherwise requires,
the following definitions of terms will govern the construction of this contract:
A. "Affiliate" means an organization or person that directly, or indirectly through one or
more intermediaries controls, or is controlled by, or is under control with, the Contractor
and that provides services to or receives services from the Contractor.
B. "AIDS Beneficiary" means an enrolled beneficiary in any month for whom a confirmed
diagnosis of Acquired Immunodeficiency Syndrome (AIDS) has been made by a treating
physician, under the definition adopted by the Centers for Disease Control (CDC),
United States Department of Health and Human Services, which is in effect for the
month as established by the Department by Contract Operations Branch (COB) policy
letter.
C. "Catastrophic Coverage Limitation" means the date beyond which the Contractor is not
at risk, as determined by the Director, to provide or make reimbursement for illness of
or injury to beneficiaries which results from or is greatly aggravated by a catastrophic
occurrence or disaster including but not limited to, an act of war, declared or undeclared,
and which occurs subsequent to enrollment.
D. "Child Health and Disability Prevention (CHDP) Program Services" means those
preventive health care services for members under 21 years of age provided in
accordance with the provisions of Title 17, California Code of Regulations (CCR),
Section 6800 et seq.
E. "Contractor" means the prepaid plan of the County of Contra Costa known as the Contra
Costa Health Plan.
F. "Covered Services" means those services set forth in Title 22, CCR, Division 3,
Subdivision 1, Chapter 4, Article 3, Section 53210. Covered services do not include:
1. Services for chronic renal dialysis and major organ transplants.
2. Services in any federal or state governmental hospital.
3. Services in any county hospital for the treatment of tuberculosis, or chronic
medically uncomplicated narcotism or alcoholism.
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County of Contra Costa 93-18608
Article II
4. Services rendered to members who have been institutionalized for more than one
full calendar month in a skilled nursing or an intennediate care facility.
5. Laboratory services provided under the State serum alphafeto protein testing
program administered by the Genetic Disease Branch of the Department of Health
Services.
6. The facility or per diem charge component of services rendered to covered
beneficiaries 64 years of age and under, institutionalized in a non-Joint
Commission on Accreditation of Hospitals (JCAH) accredited facility designated
by HHS as an Institution for Mental Disease (IMD), or services rendered to
covered beneficiaries 21 to 64 years of age institutionalized in a JCAH accredited
facility designated by HHS as an IMD, (except for covered beneficiaries who
were receiving such services before turning 21 years of age and who may
continue to require and receive such services in which case: (a) coverage may be
extended until the beneficiary's twenty-second birthday and (b)the contractor will
be liable for such services subject to subpart 4 above).
F. "Confirmed Diagnosis of AIDS" means a diagnosis of Acquired Immunodeficiency
Syndrome (AIDS) which has been formally recorded, dated, and signed by the treating
physician in an AIDS beneficiary's medical record.
G. Department" means the State Department of Health Services.
H. "HHS" means the United States Department of Health and Human Services.
I. "Director" means the Director of the State Department of Health Services.
J. "Disenrollment" means the Department-approved discontinuance of a member's
entitlement to receive covered services under the terms of this contract and the deletion
from the approved list of members furnished by the Department to the Contractor.
K. "Eligible Beneficiary" means any Medi-Cal beneficiary with one of the following aid
codes: Aid to Families with Dependent Children (AFDC) - aid codes 30, 32, 33, 34,
35, 38, 39, 40, 42, 46, 54, 59, 77, 78; Aid to the Blind (AB)-aid codes 20, 24, 26;
Aged Supplemental Security Income/State.Supplementary Payment(SSI/SSP)- aid codes
10, 14, 16; Aid to the Disabled (ATD)-aid codes 36, 60, 64, 66. Medically Indigent
Children - aid code 82; Medically Indigent Pregnant Women - aid code 86.
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County of Contra Costa Article II
L. "Emergency Services" means those services required for alleviation of severe pain, or
immediate diagnosis and treatment of unforeseen medical conditions, which, if not
immediately diagnosed and treated, would lead to disability or death.
M. "Enrollment" means the process by which an eligible beneficiary becomes a member of
the Contractor's plan, in accordance with the provisions of Title 22, CCR, Section
53420.
N. "Facility" means any premises:
1. Owned, leased, used or operated directly or indirectly by or for the Contractor
or its affiliates for purposes related to this contract, or
2. Maintained by a provider to provide services on behalf of the Contractor.
O. "Financial Security" means cash or cash equivalents which are immediately redeemable
upon demand by the Department, in an amount determined by the Department, which
will not be less than one full month's capitation.
P. "Federally Qualified Health Maintenance Organization" means an health maintenance
organization that has been determined by the Health Care Financing Administration to
be a qualified health maintenance organization under Section 1310(d) of the Public Health
Services Act.
Q. "Marketing" means any activity conducted on behalf of the Contractor where information
regarding the services offered by the Contractor is disseminated in" order to persuade
eligible beneficiaries to enroll or accept any application for enrollment in the Contractor's
prepaid health plan. Marketing also includes any similar activity to secure the
endorsement of any individuals or organization on behalf of the Contractor.
R. "Marketing Organization" means any subcontractor or sub-contractor who agrees to
provide enrollment and/or marketing services for the Contractor.
S. "Marketing Representative" means any person who is engaged in marketing activities on
behalf of the Contractor either through direct employment by the Contractor through a
marketing organization.
T. "Member" means any eligible beneficiary who has enrolled in the Contractor's plan in
accordance with the provisions of Title 22, CCR, Section 53420.
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U. "Newborn Child" means a child born to an eligible member during her membership.
V. "Prepaid Person" means a person who is entitled to receive health care services from the
Contractor in consideration of a predetermined periodic, fixed subscription premium, or
capitation payment. Prepaid person may be Medi-Cal or non-Medi-Cal.
W. "Primary Care Physician" is a physician responsible for supervision, coordinating, and
providing initial and primary care to patients; for initiating referrals for specialist care;
and for maintaining the continuity of patient care. A primary care physician is a
physician who has limited his/her practice of medicine to general practice or who is a
board-certified or board-eligible internist, pediatrician, obstetrician/gynecologist, or
family practitioner.
X. "Reinsurance" means coverage secured by the Contractor which limits the amount of risk
of liability assumed under this contract.
Y. "Service Area" Means geographic within which the contractor will provide health care
services and within which the members reside. It will comprise the entire County of
Contra Costa and approved in writing by the Department, after careful evaluation to
ensure adequate access to health care services by plan members who reside therein.
Z. "Service Location" means any location at which a member obtains any health care
service provided by the Contractor under the terms of this contract.
AA. "Service site" means the location designated by the Contractor at which members will
receive primary care physician services.
BB. "Subcontract" means and agreement entered into by the Contractor with any of the
following:
1. A Provider of health care services who agrees to furnish covered services to
members.
2. A marketing organization.
3. Any other organization or person who agrees to perform any administrative
function or service for the Contractor specifically related to securing or fulfilling
the Contractor's obligations to the Department under the tenns of this contract.
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County of Contra Costa Article II
CC. "Substantial Financial Interest" means the ownership of:
1: Common stock
2. Preferred stock
3. Warrants
4. Options
5. Loans
6. Partnership interests
7. Debt instruments
8. Any ownership interest which consists of, or is convertible to, equity
investments in this Contractor or this Contractor's subcontractor(s) or sub-
subcontractor(s).
Ownership interest in terms of fair market value will not be less than the greater of:
1. $1,000
2. Five percent or more of the total fair market value of all equity investments in the
entity, including ownership interest convertible to such investments.
DD. "Sub-subcontract" means any agreement, descending from and subordinate to a
subcontract, which is entered into for the purpose of providing any goods or services
connected with the obligations under this contract.
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County of Contra Costa Article III
ARTICLE III -- GENERAL PROVISIONS
A. Governing Authorities
This contract will be governed and construed in accordance with:
Chapter 8 (commencing with Section 14200), Part 3, Division 9, W&I Code;
Chapter 4 (commencing with Section 53000). Subdivision 1, Division 3, Title 22, CCR;
Title 42, United States Code
Title 42, Code of Federal Regulations (CFR), Parts 434 and 455;
Title 45, CFR,Part 74;
Subchapter 13 (commencing with Section 6800), Chapter 4, Part 1, Title 17, CCR, and;
All other applicable laws and regulations.
Any provision of this contract which is in conflict with the above laws and regulations
is hereby amended to conform to the provisions of those laws and regulations. This
amendment of the contract will be effective on the effective date of the statues or
regulation necessitating it, and will be binding on the parties hereto even though the
amendment may not have been reduced to writing and formally agreed upon and executed
by the parties. Amendment will constitute grounds for termination of this contract, in
accordance with the provisions of Article III, Section C, if the Contractor determines it
is unable or unwilling to comply with the provision of this amendment. If the Contractor
gives notice of termination to the Department, the parties will not be bound by the terms
of amendment, commencing from the time notice of termination is received: by the
Department until the effective date of termination.
B. Fulfillment of Obligation
No covenant, condition, duty, obligation, or undertaking continued or made a part of this
contract will be waived except by written agreement of the parties hereto, and
forbearance or indulgence in any other form or manner by either party in any regard
whatsoever will not constitute a waiver of the covenant, condition, duty, obligation, or
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County of Contra Costa Article III
undertaking to be kept, performed or discharged by the party to which the same
may apply; and, until perfonnance or satisfaction of all covenants, conditions,
duties, obligations, and undertakings is complete, the other party will have the
right to invoke any remedy available under this contract, or under law,
notwithstanding such forbearance or indulgence.
C. Should either party during the life of this contract desire a change in this contract,
including an extension of the termination date stated in Article IV, Section A, this change
will be proposed in writing to the other party. The other party will acknowledge,receipt
of the proposal within 10 days of receipt of the proposal and will have 30 days after
receipt of proposal to review and consider the proposal, to consult and negotiate with the
proposing party, and to accept or reject the proposal. Acceptance or rejection may be
made orally within said 30-day period, and confirmed in writing within 5 days thereafter.
The party proposing any change will have the right to withdraw the proposal any time
prior to acceptance or rejection by the other party. Any proposal will set forth a detailed
explanation of the reason and basis for the proposed change, a complete statement of cost
and benefits of the proposed change, and the text of the desired amendment to this
contract which would provide for the change. If the proposal is accepted this contract
will be amended to provide for the change mutually agreed to by the parties'on the
condition that the amendment is approved by the State Department of General Services,
and HHS, and the Department of Finance if necessary. If the proposal is rejected, and
is not in violation of state or federal law or regulation, or inconsistent with the other
provisions of this contract, then the contract may be terminated pursuant to Article IV,
Sections B or C.
D. Reinsurance
The Contractor may obtain reinsurance as defined in Article II, Section X, for the cost
of providing covered services under this contract as set forth herein. Reinsurance will
not limit the Contractor's liability below $5,000 per member for any 12-month period
as specified by the Department. The Contractor may obtain reinsurance for the total cost
of services provided to members by non-Contractor emergency service providers and for
90 percent of all cost exceeding 115 percent of its income during any Contractor fiscal
year.
E. Equal Opportunity Employer
The Contractor will, in all solicitation or advertisements for employees placed by or on
behalf of the Contractor, state that it is an equal opportunity employer, and will send to
each labor union or representative of workers with which it has a collective bargaining
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County of Contra Costa Article III
agreement or other contract or understanding, a notice to be provided by the
Department, advising the labor union or workers' representative of the
Contractor's commitments as an equal opportunity employer and will post copies
of the notice in conspicuous places available to employees and applicants for
employment.
F. Nondiscrimination Clause Compliance
Contractor will comply with the provisions of the Nondiscrimination Clause which is
incorporated herein and made a part hereof by this reference as Attachment I entitled
Nondiscrimination Clause (consisting of one page).
G. Discrimination Prohibition
The Contractor will not discriminate against members or eligible beneficiaries because
or race, color, creed, religion, ancestry, marital status, sexual orientation, national
origin, age, sex, or physical or mental handicap in accordance with Title IV of the Civil
Rights Act of 1964, 42 USC Section 2000d rules and regulations promulgated pursuant
thereto, or as otherwise provided by law or regulation. For the purpose of this contract
discriminations on the grounds or race, color, creed, religion, age, sex, national'origin,
marital status, sexual orientation, or physical or mental handicap include but are not
limited to the following: denying any member any covered services or availability of a
facility, providing to a member any covered service which is different, or is provided in
a different manner or at a different time from that provided to other members under this
contract except where medical indicated, subjecting a member to segregation or separate
treatment in any manner related to the receipt of any covered services, restricting a
member in any way in the enjoyment of any advantage or privilege enjoyed by' others
receiving any covered service, treating a member or eligible beneficiary differently from
others in determining whether he or she satisfies any admission, enrollment, .quota,
eligibility, membership, or other requirement or condition which individuals must meet
in order to be provided any covered services; the assignment of times or places for the
provision of services on the basis of the race, color, creed, religion, age, sex, national
origin, ancestry, marital status, sexual orientation, or the physical or mental handicap of
the participants to be served. The Contractor will take affirmative action to ensure
that members are provided covered services without regard to race, color, creed,
religion, age, sex, national origin, ancestry, marital status, sexual orientation, or
physical or mental handicap, except where medically indicated. For the purposes
of this section, physical handicap includes the carrying of a gene which may,
under some circumstances, be associated with disability in that person's offspring,
but which causes no adverse effects on the carrier. Genes will include, but are
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County of Contra Costa Article III
not limited to,Tay-Sachs trait, sickle cell trait, thalassemia trait, and X-linked hemophilia.
H. Discrimination Complaints
The Contractor agrees that copies of all grievances alleging discrimination against
members or eligible beneficiaries because of race, color, creed, sex, religion, age, nation
origin, ancestry, marital status, sexual orientation, or physical or mental handicap will
be forwarded to the Department for review and appropriate action.
I. Membership Diversity
The Contractor agrees to serve a population broadly representative of the various age,
social, and income groups within the service area, and that less than 75 percent of its
prepaid person population is of individuals receiving benefits under Title XVIII, Social
Security Act, and individuals receiving benefits under Title XIX, Social Security Act.
If the Contractor is an HMO operated by a public entity the Contractor may apply to the
Secretary, HHS for a waiver of the 75 percent requirement, based on good cause. If this
waiver is granted, then the 75 percent requirement under this contract is waived as of the
effective date of the federal waiver.
J. Inspection Rights
The Contractor will allow the Department, HHS, the comptroller General of the United
States, and other authorized state agencies, or their duly authorized representatives,
toinspect or otherwise evaluate the quality, appropriateness, and timeliness of services
performed under this contract, and to inspect, evaluate, and audit any and all books,
records, and facilities maintained by the Contractor and subcontractors, pertaining to
these services at any time during normal business hours. Books and records include, but
are not limited to, all physical records originated or prepared pursuant to the performance
under this contract including working papers, reports, financial records and books of
account, medical records, prescription files, subcontracts, and any other document
pertaining to medical and non-medical services for members. Upon request, at any time
during the period of this contract, the Contractor will furnish any record, or copy
thereof, to the Department of HHS.
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County of Contra Costa Article III
K. Notices
All notices to be given under this contract will be in writing and will be deemed to have
been given when mailed, to the Department or the Contractor at the following addresses:
State Department of Health County of Contra Costa
Services Contra Costa Health Plan
Managed Care Expansion Branch 595 Center Avenue, Suite 100
714 P Street, Room 1400 Martinez, CA 94553
Sacramento, CA 95814
L. Contractor's NLRB Declaration
Under penalty of perjury, Contractor states it has had no more than one final contempt
of court finding within a two-year period which has resulted from failure to comply with
an order of the National Labor Relations Board.
M. HMO Act Compliance
If the Contractor is a federally qualified Health Maintenance Organization, the Contractor
will provide services and benefits in the manner prescribed by Section 1301(b), and be
organized and operated in the manner prescribed by Section 1301(c) of the Public Health
Service Act (42 USC Sections 300-e(b) and (c)). This section is included herein to
comply with the provisions of 42 CFR, Section 431.522.
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County of Contra Costa Article IV
ARTICLE IV -- TERM AND TERMINATION
A. Term of Contract
This contract will become effective on January 1, 1994 and will continue : in full
force and effect through December 31, 1995 subject to the provisions of Article IX,
Sections A and H, because the State has currently appropriated and available for
encumbrance only funds to cover costs through June 30, 1994.
B. Termination - Director
The Director may terminate this contract for good cause shown at any time, subject to
the provisions of Section 14304(a), W&I code by giving written notice to the
Contractor. Notification will be given at least 30 days prior to the effective date of
termination, except in cases where the Director determines the health and welfare of
members is jeopardized by continuation of the contract, in which case the contract will
be immediately terminated. Notification will state the effective date of, and the reason
for, the termination. In addition to other grounds for termination, failure to comply with
any of the terms of this contract will constitute cause for termination.
C. Termination - Contractor
The Contractor may terminate this contract for good cause shown at any time by giving
written notice to the Director to that effect, stating the reasons for the termination. The
termination will become effective on the last day of the second calendar month following
the month in which notice of termination was given.
D. Mandatory Termination
The Director will terminate this contract in the event that: (1) the Secretary, HHS,
determines that the Contractor does not meet the requirements for participation in the
Medicaid program, Title XIX of the Social Security Act, or (2) the Department of
Corporations finds that the Contractor no longer qualifies for licensure under the
Knox-Keene Health Care Services Plan Act.
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County of Contra Costa Article IV
Under these circumstances, termination will be effective on the last day of the month in
which the Secretary, HHS, or the Department of Corporations makes a detennination,
provided that the Department provides the Contractor with at least 15 days' notice of the
tennination. In the event this notice to the Contractor is given less than 15 days prior
to the end of the month, termination will be effective on the last day of the month
following the month in which the notice was given. The Contractor agrees that 15 days'
notice is reasonable under the terms of Section 14304, W&I Code.
E. Termination of Obliizations
All obligations to provide covered services under this contract will automatically
terminate on the effective date of any termination of this contract pursuant to Sections,
B, C, or D of this Article or upon expiration of the term of this contract. The
Contractor will be responsible for providing covered services to members until the
termination or expiration of the contract and will remain liable for the processing and
payment of invoices and statements for covered services provided to members prior to
expiration or termination.
F. Local Initiative - Termination
The Director will have good cause for termination of this Contract pursuant to
Section B of this Article when a Local Initiative managed care plan begins operation in
the Service Area.
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County of Contra Costa Article,V
ARTICLE V -- DUTIES OF THE CONTRACTOR
In discharging its obligation under this contract, the Contractor will perform the following
duties:
A. Provision of Services
Provide, or arrange and pay for, covered services to any and all members needing such
services.
B. Availability and Accessibility of Service
Demonstrate the continuous availability and accessibility of adequate numbers of
institutional facilities, service locations, service sites, and professional, allied, and
supportive paramedical personnel to provide covered services including the provision of
all medical care necessary under emergency circumstances on a 24-hour-a-day, 7-day-a-
week basis. The Contractor will have as a minimum the following:
1. One full-time equivalent primary care physician per 2,000 repaid persons.
2. One full-time equivalent physician per 1,200 prepaid persons.
3. A designated emergency services facility, providing care on a 24-hour-a-day, 7-
day-a-week basis. Designated emergency services facility will have one or more
physicians and one nurse on duty in the facility at all times.
4. A vision care services system, consistent with good professional practice; which
provides that a member may be seen initially by either of the following:
a. An optometrist or and ophthalmologist.
b. A primary care physician before referral to an optometrist or an
ophthalmologist.
5. A mental health services system consistent with good professional practice which
provides that a member may be seen initially by either of the following:
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a. Psychiatrist or psychologist, or a psychiatric social worker who is working
under qualified supervision.
b. Primary care physician before referral to a mental health service provider.
6. Unless dental care services are not covered under this contract, a system,
consistent with good professional practice, that guarantees members direct access
to dental care providers without prior screening by non-dental personnel.
7. A system for informing members about contributions they can make toward the
maintenance of their own health.
Contractor will obtain departmental approval prior to make any substantial change in the
availability or location of services to be provided under this contract except in the case
of unforeseen circumstances. A proposal to change the location of services or to reduce
their availability will be given to the Department at least 30 days prior to the proposed
effective date.
C. Primary Health Care Physician
Ensure that each member has an appropriate primary care physician made available. In
the event the member becomes dissatisfied with the primary care physician the Contractor
will allow the member to choose another Contractor primary care physician.
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D. Child Health and Disability Prevention (CHDP) Program Services
Maintain and operate a system which ensures the provision of CHDP services to
members under the age of 21 in accordance with the provisions of Title 17, CCR,
Section 6800 et seq. Such system will also include the following components:
1. Annual notification, in writing, of the availability of health assessment services
and dental services (if covered by this contract), the times and places where such
services are available, and the method by which appointments for CHDP services
may be made. Notification may be given to the parent(s) or guardian of the
member under 21, or to the member directly if the member is an emancipated
minor.
2. Where a request is made for CHDP services, either directly by the member or
through a county referral, the Contractor will ensure that an appointment is made
for the member to be examined and appropriate diagnosis and treatment initiated
within 100 days.
3. In each non-emergency primary care encounter with members under the age of
21, the Contractor will ensure that:
a. The member (if an emancipated minor) or the parent(s) or guardian of the
member is advised of the CHDP services available from the Contractor
if the member has not received CHDP services in accordance with the
CHDP periodicity schedule.
b. Documentation is entered in the member's medical record which will
reveal the receipt of all CHDP services, or proof of voluntary refusal of
services in the form of a signed statement by the member (if an
emancipated minor) or the parent(s) or guardian of the member. If the
responsible party refuses to sign a statement, the refusal will be noted in
the member's medical record.
4. Monthly aggregate reporting, or PM 160-PHP reporting, submitted either monthly
or quarterly, of all CHDP health assessments and CHDP dental services (if
applicable) provided to members, in the format prescribed by the Department.
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5. Written notification and explanation of the results of the health assessment will
be supplied to the member (if a emancipated minor) or the parent(s) or guardian
of the member in a timely manner. Upon request by the member (if an
emancipated minor) or the parent(s) or guardian of the member the Contractor
will provide for additional discussion or consultation regarding the results of the
health assessment.
E. Newborn Child Coverage
Provide covered services to a newborn child under the mother's capitation payment(s)
during the month of birth and the following month.
F. Emergency Services Reimbursement
Pay for emergency services as defined in Section L of Article II received by a member
from non-Contractor providers in accordance with the provisions of 42 CFR,
Section 447, Subpart C, and Section 14454, W&I Code, and regulations adopted
thereunder. Payments to non-Contractor provider will be for the treatment, of the
emergency medical condition including medically necessary services rendered to a
member until such a time as he or she can be transferred to an appropriate provider of
the Contract. Emergency services will not be subject to prior authorization by the
Contractor. Payment by the Contractor for properly documented claims for emergency
services rendered by a non-Contractor provider will be made within 45 working days of
receipt by the Contractor, and will not exceed the lower of the following rates applicable
at the time the services were rendered by the provider:
1. The usual charges made to the general public by the provider.
2. The maximum fee-for-services rates for similar services under the Medi-Cal
program.
Disputed claims may be submitted to the Department for resolution under the provisions
of Section 14454, W&I Code and regulations adopted thereunder. The Contractor agrees
to abide by the finding of the Department in such cases, to promptly reimburse the non-
Contractor provider with 30 days of the effective date of a decision that the Contractor
is liable for payment of a claim and to provide proof of reimbursement in such form as
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the Director may require. Failure to reimburse the non-Contractor provider and provide
proof of reimbursement to the Department within 30 days will result in set offs from two
or more capitation payments, as determined by the Director in accordance with Section
14454, W&I Code Section 53620 through 53702, Title 22, CCR.
G. Organizational and Administrative Capability
Have the organization and administrative capabilities to carry out its duties and
responsibilities under the contract, This will include as a minimum the following:
1. A medical director to oversee and be responsible for the proper provision of
covered services to members.
2. Designated persons, qualified by training or experience, to be responsible for the
medical record service.
3. Member and enrollment reporting systems.
4. A member grievance procedure.
5. Data reporting capabilities sufficient to provide necessary and timely reports to
the Department.
6. Financial records and books of account maintained on the accrual basis, in
accordance with generally accepted principles, which fully disclose the disposition
of all Medi-Cal program funds received.
H. Subcontracts
Execute subcontracts pursuant to Title 22, CCR, Section 53250 and Article X of this
Contract.
I. Professional Review System
Use a professional review system in accordance with Title 22, CCR, Section 53280, for
evaluating the appropriateness and quality of the covered services provided to members
and for periodically reviewing the performance of health personnel, the utilization of
services and facilities, costs, and the standards for the acceptable medical care.
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J. Member Medical Records
Maintain for each member who has received medical services during enrollment, a
eligible medical record kept in detail consistent with good medical and professional
practice which permits effective internal professional review and external medical audit
processes, and which facilitates an adequate system for follow-up treatment. Medical
records will be maintained in accordance with Title 22, CCR, Section 52384.
K. Medical Review Assistance
Provide any necessary assistance to the Department in its conduct of facility inspections
and medical reviews of the quality of care being provided to members. Contractor will
correct deficiencies as identified by such inspections and reviews according to the time
frames delineated in the resulting reports.
L. Responsibility for Marketing Activity
Be responsible for all marketing activity conducted on behalf of the Contractor.
Contractor will be held liable for any and all violations by any marketing representatives
of Article 4 (commencing with Section 53400), Chapter 4, Subdivision 1, Division 3,
Title 22 CCR.
M. Submittal of Applications
Submit enrollment applications in the following manner:
1. If the Contractor has a current enrollment of less than 5,000 members, the
Contractor will either: (a) submit hard copy enrollment applications only: or (b)
submit enrollment application data in the form of magnetic tape, in the formate
designated by the Department, which will be supported by hard copy backup
enrollment application.
2. If the Contractor has a current enrollment of 5,000 or more, enrollment data will
be submitted to the Department via magnetic tape, in the format specified by the
Department, and will be accompanied by hard copy backup enrollment
applications.
3. Hard copy enrollment applications will be submitted to the Department within 15
days of the eligible beneficiary's signing of the application.
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N. Marketing Presentations
Ensure that all marketing presentations made to eligible beneficiaries contain adequate
information about the Contractor to allow beneficiaries to exercise informed judgment
in choosing to enroll in the Contractor's plan. Such information and procedures will
conform with Title 22, CCR, Section 53404, as a minimum.
O. Member Identification
Provide an identification card to each member, within seven days after the effective date
of enrollment, which identifies the member and authorizes the provision of covered
services to the member if eligible. Identification card will also specify that emergency
services rendered to the member by non-Contractor providers are reimbursable by the
Contractor without prior authorization.
P. Notification to Members About Covered Services
Within seven days after the effective date of enrollment notify members or the member's
family unit, in writing, concerning the type, scope, and duration of covered services to
which they are entitled. The format of notification will be approved by the Department
prior to use and will include:
1. The effective date of enrollment.
2. The term of enrollment.
3. A description of all covered services provided by the Contractor and exclusions
of limitations thereto, and charges therefore, if applicable.
4. An explanation of the procedure for obtaining covered services.
5. In the case of a medical foundation or independent practice association, the
address and telephone number of each primary care physician, dentist,
optometrist, and psychologist.
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6. In the case of other plans, the address and telephone number of each services site
and the location of primary care physicians, dentists, optometrists, and
psychologists.
7. The address and telephone number of each hospital, pharmacy, and skilled
nursing facility, together with a explanation of the benefits and services available
at these facilities and the hours and days of their operation.
8. The name, telephone number, and service site address of the primary care
physician chosen by or otherwise made available to the member.
9. Locations, telephone numbers, and procedures for obtaining health services in the
event of an emergency.
10. Explanation of and the procedure for obtaining health services rendered in
emergency circumstances occurring outside the Contractor's services area.
11. The causes for which a member will lose entitlement to receive services under
this contract.
12. The grievance procedure including the name, address, and telephone number of
the person(s) responsible for resolving grievances or initiating the grievance
procedure.
13. Disenrollment procedures, including and explanation of the member's right to
disenroll without cause at any time.
14. The appropriate use of health care services.
15. Information concerning transportation arrangements offered by the Contractor.
16. Any other information determined by the Department to be essential for the
proper receipt of covered services.
This information will be revised annually, if necessary, by the Contractor and distributed
to each member or the member's family unit.
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Q. Notification to Members About Changes in Covered Services
Notify members in writing of any substantial changes in the availability of covered
services being provided by the Contractor at least 14 days prior to the effective date of
such changes, or as soon as possible in cases of unforeseen circumstances. Notification
will be approved by the Department prior to release, and need only be sent to those
members affected by the change.
R. Beneficiary Notification of Denial, Deferral or Modification of Requests for Prior
Authorization
1. The Contractor will comply with the final judgement and order issued by the
United State District Court in Action No. CIV S-83-1451 LKK know as the
"Jackson versus Rank" lawsuit by providing written notification to enrolled
beneficiaries and, if known, their authorized representatives at the time of denial,
deferral or modification of a request for prior approval to provide a health care
services, as specified in the court order, when all of the following conditions
exists:
A. The request is made by a health care provider who has a formal
arrangement with the PHP to provide services to Medi-Cal enrollees.
B. The request is made by the provider through the formal prior authorization
procedures operated by the Contractor.
C. The services for which prior authorization is requested is a Medi-Cal
covered service for which the Contractor has established a prior
authorization requirements.
D. The prior authorization decision is being made at the ultimate level of
responsibility within the Contractor's organization for approving, denying,
deferring or modifying the service requested but prior to the point at
which the beneficiary must initiate the Contractor's grievance procedure.
2. The written notification will be given by the Contractor to the beneficiary and the
beneficiary's representative on the standardized form approved by the Department
and will inform the beneficiary of all the following:
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A. The beneficiary's right to, and method for obtaining, a fair hearing to
contest the denial, deferral or modification action,
B. The beneficiary's right to represent himself/herself at the fair hearing or
to be represented by legal counsel, friend or other spokesperson.
C. The name and address of the Contractor and the State toll-free telephone
number for obtaining information on legal service organizations for
representation.
The notice to the beneficiary may inform the beneficiary that the beneficiary may
file a grievance concerning the Contractor's action using the Contractor's
grievance process prior to or concurrent with the initiation of the fair hearing
process.
3. The Contractor will tender required notification to beneficiaries and the
representative in accordance with the time frames set forth in the court order.
S. Member Grievance Procedure
Establish and maintain a procedure for the prompt receipt, processing, and resolution of
member grievances in accordance with Title 22, CCR, Section 53260.
T. Disenrollment Submittal
Process through the grievance procedure and submit to the Department, requests for
disenrollment no later than the calendar date set forth in CCR, for the month following
the month in which the member requests disenrollment, except for those submitted
pursuant to Sections 14303.1(d), 14303.2(c)(3), and 14409(b)(5), W&I Code which will
be forwarded to the Department within 5 days of member signature. All requests for
disenrollment will be submitted on forms prescribed by the Department.
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U. Financial Resources
1. Maintain adequate financial resources to carry out its obligations tinder this
contract. The financial resources will meet, but not be limited to, the following
minimum levels, as determined by the Department:
a. Tangible net equity as defined in Title 10, CCR Section 1300.76.
b. A working capital ration of at least 1:1.
2. Ensure that administrative costs incurred by the Contractor and its affiliate(s) does
not exceed the limits established by Title 10, CCR, Section 1300.78.
V. Contractor Risk in Providing Services
Assume the total risk of providing the covered services on the basis of the periodic
capitation payment for each member, except as otherwise allowed in this contract. Any
monies not expended by the Contractor after having fulfilled obligations under this
contract will be retained by the Contractor.
W. Financial Security
Provide satisfactory evidence of and maintain financial security in an amount and manner
specified by the Department. Such financial security will remain in effect for at least 90
days following termination of expiration of this contract or until, in the judgment of the
Department the obligations set forth in this contract are fulfilled provided that prior to
the expiration of such ninety (90) days; the Department has notified the contractor in
writing of the reasons for extending the ninety (90) day period and what actions the
contractor is required to take to meet obligations.
X. Catastrophic Coverage Limitations
Return a prorated amount of the capitation payment following the Director's invocation
of the catastrophic coverage limitation. The amount returned will be determined by
dividing the total capitation payment by the number of days in the month. This amount
will be returned to the Department for each day in the month after the Director has
invoked the catastrophic coverage limitation clause.
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Y. Recovery from Other Sources or Providers
Make reasonable effort to recover the value of covered services rendered to members
whenever the members are covered for the same services, either fully or partially, under
any other state or federal medical care program or under other contractual or legal
entitlement including, but not limited to, a private group or indemnification program, but
excluding instances of the tort liability of a third party. The monies recovered are
retained by the Contractor.
Z. Third-Party Tort Liability
Make no claim for recovery of the value of covered services rendered to a member when
the recovery would result from an action involving the tort liability of a third party or
casualty liability insurance including Workers' Compensation awards and uninsured
motorists coverage. The Contractor will identify and notify the Department of cases in
which an action by the Medi-Cal recipient involving the tort or Workers' Compensation
liability of a third party could result in recovery by the recipient of funds to which the
Department has lien rights under Article 3.5, Part 3, Division 9, W&I Code. These
cases will be referred to the Department within 10 days of discovery. To assist the
Department in exercising its responsibility for such recoveries, Contractor will meet the
following requirements:
1. If the Department requests payment information and/or copies of paid invoice/claims for
covered services to an individual enrollee, Contractor will deliver the requested
information within 10-30 days of the request. The value if the covered services will be
calculated as the usual, customary and reasonable charge made to the general public for
similar services or the amount paid to subcontracted providers or out of plan providers
for similar services.
2. Information to be delivered will contain the following data items:
a. Enrollees name.
b. Full 14 digit Medi-Cal number.
C. Social Security Number.
d. Date of birth.
e. Contractor name.
f. Provider name (if different from Contractor)
g. Dates of service.
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h. Diagnosis code and/or description of illness/injury
i. Procedure code and/or description of services rendered
j. Amount billed by a subcontractor or out of plan provider to Contractor (if
applicable)
k. Amount paid by other health insurance to Contractor or subcontractor.
1. Amount and date paid by Contractor to subcontractor or out of plan
provider (if applicable).
m. Date of denial and reason (if applicable).
3. Contractor will identify to the Department the name, address and telephone
number of the person responsible for receiving and complying with requests for
mandatory and/or optional at-risk service information.
4. If Contractor received any requests by subpoena from attorneys, insurers or
beneficiaries for copies of bills, Contractor will provide the Department with a
copy of any document released as a result of the request, and will provide the
name and address and telephone number of the requesting party.
AA. Books and Records
Maintain books and records necessary to disclose how the Contractor discharged its
obligations under this contract. These books and records will disclose the quantity of
covered services provided under this contract, the quality of those services, the manner
and amount of payment made for those services. The persons eligible to receive covered
services, the manner in which the Contractor administered its daily business, and the cost
thereof.
These books and records will include, but are not limited to, all physical records
originated or prepared pursuant to the performance under this contract including working
papers; reports submitted to the Department; financial records; all medical records,
medical charts and prescription files; and other documentation pertaining to medical and
non-medical services rendered to members.
These books and records will be maintained for a minimum of five years from the
termination date of this contract, or, in the event the Contractor has been duly notified
that the Department, HHS, or the Comptroller General of the United States, or their duly
authorized representatives, have commenced an audit or investigation of the contract,
until the matter under audit or investigation has been resolved, whichever is later.
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In addition the contractor must assure that all records necessary to validate a confirmed
diagnosis of AIDS as defined by the Centers for Disease Control, U.S. Department of
Health and Human Services for an AIDS Beneficiary for whom the Contractor is
claiming the AIDS beneficiary rate of reimbursement are retained and accessible for
review by the Department. These records will be made available to the Department
within 60 days of a formal written request.
BB. Reporting Requirement
Furnish the following reports and information to the Department (unless specifically
exempted from reporting pursuant to Section 14308, W&I Code):
1. On an annual basis:
a. The financial audit report required by Article XI. This report will be
submitted to the Department no later than 90 calendar days after the close
of the Contractor's fiscal year.
b. A disclosure statement in compliance with Article V, Section EE.
C. An update of the provider listing required in Title 22, CCR, Section
53312(b)(2). The Contractor will list primary care physicians by service
site, and all other physicians by specialty designation.
2. On a quarterly basis (within 45 calendar days of the end of each quarter under
this contract):
a. Utilization and statistical data in compliance with Title 22, CCR, Section
53314.
b. Financial reports required by Title 22, CCR, Section 53324(c), unless
waived in writing by the Department.
C. CHDP reports as required in Article V, Section D.
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3. Other reports to be submitted to the Department include:
a. Information requested by the Department to conduct medical reviews or
contract monitoring in accordance with Section 14457, W&I Code.
b. Financial reports relevant to affiliates as specified in Title 22, CCR,
Section 53330.
C. Copies of any financial reports submitted to other public or private
organization as specified in Title 22, CCR, Section 53324(d).
d. Notification of possible third-party tort liability situations, including
Workers' Compensation situations. This information will be submitted
within 10 calendar days of discovery.
e. Names of contractor's employees who are subject to the requirement of
Title 22, CCR, Section 53600(f). This information will be reported to the
Department within 10 days of the employment date.
f. Information necessary for evaluation of compliance with Section 53402,
Title 22, CCR.
g. A completed Disclosure Form at the time the contract is executed,
annually with the Contractor's Certified Public Accountant audit and
financial statement, and within 35 days of a written request by the
Department of HHS or 35 days of any change in previously submitted
information.
CC. Obtaining Department Approval
Obtaining written approval from the Department prior to implementing or using the
following:
1. Providers of covered services, except for providers of seldom-used or unusual
services as determine by the Department.
2. Facilities
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3. Subcontracts and sub-subcontracts with providers or for management services if
the Contractor is not a qualified Health Maintenance Organization (HMO).
4. Marketing activities.
5. Marketing materials, promotional materials, and public information releases
relating to performance under this contract; member service guides; member
newsletters; and provider claim forms unique to the contract.
6. Member grievance procedure.
7. Member disenrollment procedure.
8. Enrollment, disenrollment, and grievance forms.
Revisions to these items must be approved by the Department prior to taking effect.
DD. Transfer of Care
Prior to the termination or expiration of this contract and upon request by the
Department, the Contractor will assist the State in the orderly transfer of member
medical care. In doing this, the Contractor will make available to the Department copies
of medical records, patient files, and any other pertinent information, including
information maintained by any subcontractor, necessary for efficient case management
of members, as determined by the Director. Costs of reproduction will be borne by the
Department.
EE. Disclosure Statement
1. File an annual statement with the Department disclosing any purchases or leases
of services, equipment, supplies, or real property from an entity in which any of
the following persons have a substantial financial interest:
a. Any person also having a substantial financial interest in the Contractor.
b. Any Director, officer, partner, trustee, or employee of the Contractor.
C. Any member of the immediate family of any person designated in (a) or
(b) above.
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2. Comply with federal regulations 42 CFR 455.104 (disclosure by providers and
fiscal agents: Information on ownership and control), 42 CFR 455.105
(Disclosure by providers: Information related to business transactions), and 42
CFR 455.106 (Disclosure by providers: Information on persons convicted of
crimes) in accordance with Article V, Section BB.
FF. Consumer Participation
Provide a mechanism for members to participate in establishing the public policy of the
Contractor in accordance with the provisions of Title 10, CCR, Section 1300.69.
GG. Participation in Health Care Options
Supply the Department or counties with sufficient printed materials, in a format
designated by the Department, as may be required to carry out the objectives of the
Health Care Options program operated by the Department and the county or counties in
which the Contractor operates. The Contractor will also make every effort to enroll
those beneficiaries who choose, as a result of a Health Care Options presentation, to
enroll with the Contractor.
HH. Timely Submission of Risk Limit Claims
Department's liability for payment of claims submitted pursuant to Article VI, Section
L (Risk Limitation) is time limited in accordance with this paragraph:
1. "Timely Submission" of Claims
Claims submitted pursuant to Article VI, Section L (Risk Limitation) will not be
paid by the Department unless received by the Department not later than the last
day of the sixth (6th) month following the end of the twelve (12) month period
(set forth in Article VI, Section L) in which they were incurred.
2. "Good Cause for late Billing of Claims"
The time specified for submission of claims pursuant to Article VI, Section L, as
set forth herein, may be extended for a period not to exceed one (1) year upon
a finding of 'good cause" by the Director in the following circumstances:
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a. Where the claim involves health coverage, other than Medi-Cal, and the
delay is necessary to permit the Contractor to obtain payment, partial
payment, or proof on non-liability of such other health coverage.
b. Where the claim submission was delayed due to eligibility certification or
determination by the State or County.
C. Where there was a substantial interference with claim submission due to
damage to or destruction of the Contractor's (or subcontractor's) business
office or records by a natural disaster, including fire, flood or earthquake
or other similar circumstances.
d. Where delay in claims submission was due to other circumstances that are
clearly beyond the control of the Contractor, provided that circumstances
that will not be considered beyond the control of the Contractor include,
but are not limited to, those circumstances described in subparagraph 3.
3. Circumstances Lacking "Good Cause" for Late Billing
It is agreed between the parties that the following circumstances will not be
considered as "good cause" for extension of the time for submission of claims
pursuant to Article VI, Section L.
a. Negligence or delay of the Contractor or Contractor' employees, agents,
and subcontractors.
b. Misunderstanding of or unfamiliarity with Medi-Cal regulations, or the
terms of this contract.
C. Illness, absence or other incapacity of a Contractor's employee, agent or
subcontractor responsible for preparation and submission of claims.
d. Delays caused by the United States Postal Services or any private delivery
service.
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II. Submission of AIDS Invoice
As an express condition precedent to reimbursement at the AIDS Beneficiary rate, the
contractor will submit an invoice in accordance with Article IX, Section I to the
Department. The invoice submitted by the Contractor in the sixth (6th) month following
the end of the rate year commencing October 1, 1993 and ending June 30, 1994, or any
subsequent rate year commencing October 1, and ending June 30, of the following year,
will be the final invoice on which the contractor is entitled to claim the AIDS Rate for
a month of eligibility during the rate year.
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ARTICLE VI -- DUTIES OF THE STATE
In discharging its obligations under this contract, the State will perform the following duties:
A. Payment for Services
Pay the appropriate capitation payments set forth in Article IX to the Contractor for each
eligible member under this contract, except as provided in Article VII, Section E, and
ensure that payments are reasonable and do not exceed the amount set forth in 42 CFR,
Part 447.361. Payments are to be made monthly for the duration of this contract.
B. Medical Reviews
Conduct medical reviews at least once every 12 months in accordance with the provisions
of Section 14456, W&I Code, and issue medical review reports to the Contractor
detailing findings, recommendations, and corrective action, as appropriate.
C. Facility Inspections
Conduct on-site inspections of health facilities prior to approval of their use for providing
services to members under the terms of this contract. Inspections for continuing facility
adequacy will be conducted periodically thereafter.
D. Monitoring for Compliance
Monitoring the operation of the Contractor for compliance with the provisions of this
contract, applicable state law, and regulations. The monitoring activities will include,
but not be limited to, inspection and auditing of Contractor Facilities, management
systems and procedures, and books and records as the Director deems appropriate, at
any time during the Contractor's or facility's normal business hours.
E. Enrollment Processing
Review applications for enrollment submitted by the Contractor, check the eligibility of
applicants for services under this contract, and provide to the Contractor a list of
members on a monthly basis, effective the first of the month.
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F. Disenrollment Processing
Review and process requests for disenrollment and notify the Contractor and the member
of its decision. On an annual basis, provide in writing a schedule of the last calendar
date in each month by which requests for disenrollment must be submitted to the
Department by the Contractor to assure that disenrollment occurs in compliance with
Section 14413 of the W&I Code. The Department may revise the schedule, as
necessary, to assure that the requirements of Section 14413 are met. The Department
will provide reasonable notice to the Contractor of revisions to the schedule.
G. Testing and Certification of Marketing Representatives
Test all Contractor marketing representatives for knowledge of the program prior to their
engaging in marketing activities on behalf of the Contractor. Certify as qualified
marketing representatives, those persons demonstrating adequate knowledge of the
program, provided they are of good moral character.
H. Approval Process
Acknowledge in writing, within five working days of receipt, the receipt of any material
sent to the Department by the Contractor under the provisions of Article V, Section BB.
Within 60 days of receipt, approve in writing the use of the material or provide the
Contractor with a written explanation why its use is not approved.
I. Program Information
Provide the contractor with complete and current information with respect to pertinent
statutes, regulations, policies, procedures, and guidelines affecting the operation of this
contract.
The Department will furnish to the contractor a Managed Care Expansion Branch
(MCEB) Policy letter which sets forth the applicable Centers for Disease Control (CDC),
United States Department of Health and Human Services, definition of AIDS, and the
month or months to which the definition is applicable. The Department will update this
policy letter to reflect revisions made by CDC in its AIDS definition.
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J. Sanctions
Apply sanctions, in accordance with Title 22, CCR, Section 53350, to the Contractor for
violations of the terms of this contract, applicable state law and regulations.
K. Catastrophic Coverage Limitation
Limit the Contractor's liability to provide or arrange and pay for care for illness of, or
injury to, members which results from or its greatly aggravated by, a catastrophic
occurrence or disaster.
L. Risk Limitation
Terminate the Contractor's financial liability to provide covered services to a member
on a risk basis in those situations where, during the 12-month period beginning July
1, 1993 and ending June 30, 1994, or any succeeding 12-month period commencing
July 1st, and ending the following June 30th, the member has received medically
necessary covered services, as determined by the Department, from the Contractor in an
amount in excess of $50,000, based upon Medi-Cal schedules of reimbursement, and
exclusive of payments recovered by Contractor from third-party payors. Affected
members will not be disenrolled because of their need of services in excess of$50,000,
and the Contractor will be responsible to provide or arrange and pay for, medically
necessary covered services for members. Contractor will be reimbursed for such
continuing care in excess of $50,000 by the Department, based on Medi-Cal schedules
of reimbursement or the Contractor's costs, whichever is lower, and exclusive of
payments recovered by the Contractor from third-party payors, as determined by the
Department upon Contractor submission to the Department of appropriately documented
claims for services provided during the 12-month period specified above.
The dates set forth in this paragraph only serve to establish the beginning and ending
dates of the risk limitation period and will not be construed to extend the Contractor's
responsibility to render services under this contract nor the Department's responsibility
to pay for services rendered beyond the date on which this contract terminates. The
establishment of a risk limitation period that extends beyond the term of the current
contract contemplates the possibility of(but does not bind the parties to) renewal of the
contract for an additional term. In the event the contract is terminated or not renewed,
the risk limitation period will terminate upon termination of the contract.
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M. Termination of Contract
Notify members of their health care benefits and options viable upon termination or
expiration of this contract.
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ARTICLE VII -- ELIGIBILITY AND ENROLLMENT
A. Voluntary Enrollment
Enrollment will be voluntary.
B. Open Enrollment--General
Eligible Medi-Cal beneficiaries residing within the service area may voluntarily apply for
enrollment under this contract at any time during the term of this contract. Beneficiaries
will be accepted by the Contractor in the order in which they apply, up to the limits
imposed in Section C, and without regard to physical or mental condition, age, sex, race,
religion, creed, color, national origin, marital status, sexual orientation, or ancestry.
C. Enrollment totals
Total enrollment under this contract will not exceed 15,000 members in the following aid
categories:
NUMBER OF
AID CATEGORY CODE ENROLLEES
Aid to families 30,32,33,34, 13,900
with Dependent 35,38 39,40
Children (AFDC) 42,46,54,59
77,78
Aid to the Blind (AB) 20,24,26 30
Aged Supplemental Security
Income/State Supplementary
Payment (SSI/SSP) 10,14,16 360
Medically Indigent Children/
Pregnant Women 82,86 45
Aid to The Disabled (ATD) 36,60,64,66 665
Total 15,000
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County of Contra Costa Article VII
D. Coverage
Member coverage will begin at 12:01 a.m. on the first day of the calendar month for
which the beneficiary's name is added to the approved list of members furnished by the
Department to the Contractor. The term of membership will continue indefinitely unless
this contract expires, is terminated, or the member is disenrolled under Section F of this
Article.
E. Enrollment Restriction
Enrollment may proceed to the plan's maximum total number of members in each aid
category unless restricted by the Department. Restrictions will be defined in writing and
the Contractor notified at least 10 days prior to the state of the period of restriction.
Release of restrictions will be in writing and transmitted to the Contractor at least 10
days prior to the date of the release.
Contractor will provide or arrange and pay for services to members enrolled in excess
of the maximum specified in Section C, or in violation of enrollment restrictions.
However, the Department will not remit capitation payments for members so enrolled.
F. Disenrollment
Disenrollment may take place under the following conditions subject to approval by the
Department in accordance with the provisions of Title 22, CCR, Section 53440:
1. Disenrollment of a member is mandatory when:
a. The member request disenrollment.
b. The member's eligibility as a Medi-Cal beneficiary or eligibility for
enrollment in the plan is terminated.
C. Enrollment was in violation of Title 22, CCR, Sections 53400, 53401,
53401.1, 53402, 53404, or 53406.
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d. Disenrollment is requested in accordance with Title 22, CCR, Sections
53508 or 53510.
e. There is a change of a member's place of residence to outside the plan's
service area.
2. Disenrollment requests based on the need of a member for the services of a
skilled nursing facility or intermediate care facility for at least one month after
the month of admission to the facility will be accompanied by documentation
sufficient to ensure the member's orderly transfer from the Contractor to the
Medi-Cal fee-for-service system, as determined by the Department.
Disenrollments will become effective on the first day of the second month
following the member's admission to the facility, provided that the disenrollment
is requested at least 30 days prior to such date.
3. The Contractor will have the right to recommend to the Department the
disenrollment of any member in the vent of a breakdown in the "doctor-patient
relationship" which makes it impossible for the Contractor's providers to render
services adequately to a member or in the event any member has abrogated the
enrollment agreement by habitually seeking and receiving covered services, other
than emergency care, from a provider other than the Contractor or
subcontractors. Disenrollment requests will be processed through the grievance
procedure as formal grievances and the decision to allow disenrollment of any
member will be solely that of the Department.
4. Membership will cease at midnight on the last day of the calendar month in which
the member's disenrollment request is approved by the Department. On the first
day of the month following the approval of the disenrollment request, the
Contractor is relieved of all obligations, to provide covered services to the
member under the terms of this contract The Contractor agrees in turn to return
to the Department any capitation payment forward to the Contractor for persons
not enrolled under this contract.
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ARTICLE VIII -- STANDARDS
A. Applicability of Standards
Each provider who delivers covered services to members will meet applicable
requirements established under Titles XVIII and XIX of the Social Security Act, unless
exempted from those provisions of Chapters 3 and 4, Subdivision 1, Division 3, Title 22,
CCR, and the standards expressed in this contract. All providers of covered services
must be qualified in accordance with current applicable legal, professional, and technical
standards and appropriately licensed, certified or registered.
B. Physician Services
The contractor will provide physician services:
L Directly through physicians who are employees of the Contractor, who have
agreements with the Contractor to provide health care services, or, are providers
of unusual or seldom-used health care services, or
2. Under arrangements with one or more groups of physicians (organized on a group
practice or individual practice basis) under which each group is reimbursed for
its services primarily on the basis of an aggregate fixed sum or on a per capita
basis, regardless of whether the individual physician members of any group are
paid on a fee-for-service or other basis.
C. Medical Director
The Contractor will appoint a physician as medical director in accordance with Title 22,
CCR, Section 53246.
D. Pharmaceutical Services and Prescribed Drugs
The Contractor will provide pharmaceutical services and prescribed drugs, either directly
or through subcontracts, in accordance with Title 22, CCR, Section 53214. As a
minimum, such pharmaceutical services and drugs will be available to members during
service site hours. When the course of treatment provided to a member by a Contractor
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provider under emergency circumstances requires the use of drugs, a sufficient quantity
of such drugs will be provided to the member to last until the member can reasonably
be expected to have a prescription filled.
E. Facilities
Facilities used by the Contractor for providing covered services will comply with the
provisions of Title 22, Section 53230.
F. Marketing_Representative
The Contractor will ensure, in addition to the requirements of Title 22, CCR, Section
53400 through 53458, that:
1. All marketing representatives have satisfactorily completed the Contractor's
marketing orientation and training program and the Department's examination for
marketing representatives prior to engaging in marketing activities on behalf of
the Contractor.
2. A marketing representative will not provide marketing services on behalf of more
than one Contractor.
3. Marketing representatives do not engage in any marketing or enrollment practices that
discriminate against an eligible beneficiary because of race creed, age, color, sex,
religion, national origin, ancestry, marital status, sexual orientation, physical or mental
handicap, or health status.
G. Laboratory Certification
All laboratory testing sites including physician office sites/clinics, providing services
under this contract must have either a Clinical Laboratory Improvement Amendment
(CLIA) certificate of waiver or a certificate of registration along with a CLIA
identification number. Those laboratories with certificates of waiver will ,provide only
the eight types of tests permitted under the terms of their waiver. Laboratories with
certificates of registration may perform a full range of laboratory tests.
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County of Contra Costa Article IX
ARTICLE IX -- PAYMENT
A. Amounts Payable
The maximum amount payable for the 1993-94 Fiscal Year ending June 30, 1994 will
not exceed $8,638,000. Any requirement by the Department and the contractor for the
period of the contract subsequent to June 30, 1994 will be dependent upon the availability
of future appropriations by the Legislature for the purpose of this contract. If funds
become available for purposes of this contract from future appropriations by the
Legislature, the maximum amount payable under this contract for:
o The 1994-95 Fiscal Year Ending June 30, 1995 will not exceed ................
$16,265,808.
o The 1995-96 Fiscal Year Ending June 30, 1996 will not exceed ................
$8,132,904.
o The maximum amount payable under this contract will not exceed
............$33,036,712.
B. Capitation Rates
The State will remit to the Contractor a capitation payment for each member, for each
month in which the member is eligible for Medi-Cal benefits and appears on the
approved list of members supplied to the Contractor by the Department. Capitation
payments will be made in accordance with the following schedule of capitation payment
rates:
MEDICALLY NEEDY ONLY - NO
PUBLIC ASSISTANCE SHARE OF COST
Aged $ 113.84 Aged $ 164.17
AFDC $ 95.98 AFDC $ 138.88
Disabled/Blind $ 214.91 Disabled/Blind $ 917.72
AIDS $ 1,936.71 AIDS $1,936.71
MI Children $ 185.47
MI Pregnant Women $ 626.21
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County of Contra Costa Article IX
C. Rates Constitute Payment in Full
The capitation payment constitutes payment in full by the Department on behalf of a
member for all covered services required by the member, subject to the provisions of
Article VI, Section L and for all administrative costs incurred by the Contractor in
providing or arranging for services, but does not include payment for the recoupment of
current or previous losses incurred by the Contractor. The basis for the determination
of the capitation payment rates is outlined in Attachment II, consisting of 13 pages,
herein incorporated by this reference and made part of this Contract.
D. Determination of Rates
The capitation payment rates are set by the Department on a yearly basis in conjunction
with the passage of the Budget Act of the State of California. The Department will
annually review the capitation rates, applicable to Contractor, to determine whether rates
will be increased, decreased, or remain the same in accordance with the provisions of
Section 14301(a), W&I Code, and regulations adopted thereunder. If it is determined
by the Department that Contractor's capitation rates should be increased or decreased,
the increase or decrease may be effectuated through an amendment to this contract in
accordance with the provision of Article III, Section C, subject to the following
provisions:
1. The amendment will be effective as of October 1 of each year covered by this
contract.
2. In the event there is any delay in a determination to increase or decrease
capitation rates, and an amendment may not be processed in time to permit
payment of new rates commencing October 1, the payment to the Contractor will
continue at the rates then in effect. Continued payment will constitute interim
payment only. Upon final approval of the amendment providing for a rate
change, the Department will make adjustments for those months for which interim
payment was made.
3. In the event that the Contractor and the Department agree upon new rates and
executes an amendment to the contract, payment of new rates will commence
October 1, whether or not the rates agreed upon and the amendment
implementing such rates have been finally approved by all state control agencies.
By accepting payment of new annual rates prior to full approval by all State
control agencies of the amendment to this contract implementing such new rates,
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County of Contra Costa Article IX
the Contractor stipulates to a confession of judgment for any amounts received
in excess of the final approved rate. If the final approved rate differs from the
rates agreed upon the Contractor and the Department:
a. Any underpayment by the State will be paid to the Contractor within 30
days after final approval of the new rates.
b. Any overpayment to the Contractor will be recaptured by the State's
withholding the amount due from the Contractor's next capitation check.
If the amount to be withheld from subsequent capitation checks exceeds
25 percent of the capitation payment for that month, amounts up to 25
percent will be withheld from successive capitation payments until the
deficiencies are fully recovered by the State. This subsection is included
herein to comply with Section 14301(a), W&I Code.
E. Redetermination of Rates -- Obligation Changes
The capitations rates may be adjusted during the rate year to provide for a change in
obligations which results in an increase or decrease in costs to Contractor, in accordance
with the provisions of Section 14301(c), W&I Code and regulations adopted thereunder.
Any adjustment may be effectuated through an amendment to this contract in accordance
with the provisions of Article III, Section C, subject to the following provisions:
1. The amendment will be effective as of the first day of the month in which the
change in obligations is effective, as determined by the Department.
2. In the event the Department is unable to process the amendment in time to permit
payment of the adjusted rates as of the month in which the change in obligations
is effective, payment to Contractor will continue at the rates then in effect. The
continued payment will constitute interim payment only. Upon final approval of
the amendment providing for the change in obligations, the Department will make
adjustments for those months for which interim payment was made.
F. Catastrophic Coverage Limitation
Catastrophic coverage limitation as defined in Section C of Article II will become
effective when the Director determines that a major catastrophe or disaster has occurred.
When a determination is made by the Director, the Contractor's liability under this
contract will tenninate.
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County of Contra Costa Article IX
Any proration of the monthly capitation payment due to this provision will be based upon
the number of days in the month for which the payment is made.
G. Decapitation
In the event that the Department determines that a member has either been improperly
enrolled, or should have been disenrolled with an effective date in a prior month, the
Department reserves the right to deduct capitation from the Contractor which was paid
on behalf of such member and to absolve the Contractor from all financial and other risk
for the provision of services to a member under the terms of this contract.
H. Limitations to Federal Financial Participation
1. It is mutually understood between the parties that this contract may have been
written before ascertaining the availability of congressional appropriation of
funds, for the mutual benefit of both parties in order to avoid program and fiscal
delays which would occur if the contract were executed after the determination
was made.
2. This contract is valid and enforceable only if sufficient funds are made available
to the State by the United State government for the Fiscal year 1988-89 for the
purpose of this program. In addition, this contract is subject to any additional
restriction, limitations or conditions enacted by the Congress or any statute
enacted by the Congress which may affect the provisions, terms or funding of this
contract in any manner.
3. It is mutually agreed that if the Congress does not appropriate sufficient funds for
the program, this contract will be amended to reflect any reduction in funds.
4. The Department has the option to void the contract under the 30-day cancellation
clause or to amend the contract to reflect any reduction of funds.
I. Payment of AIDS Beneficiary Rates
Payment of the AIDS Beneficiary Rate to the contractor will be contingent upon the
following:
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1) The contractor will be entitled to claim and be reimbursed at the AIDS
Beneficiary Rate. The AIDS rate will be made in lieu of any other capitation
payment made for an AIDS beneficiary in any month.
2) Capitation payments at the AIDS Beneficiary Rate will commence effective with
the month in which the confirmed diagnosis of AIDS under the applicable CDC
definition is made for a beneficiary.
3) The contractor will submit an invoice for each month to the department's MCEB
by the 25th day of the prior month. The invoice will include the following:
a. A listing of all AIDS beneficiaries identified by Medi-Cal numbers only
for whom the Contractor is claiming the AIDS rate. Beneficiary names
should not be used.
b. The month(s) and year(s) for which the AIDS rate is being claimed for
each beneficiary listed.
C. The capitation rate initially paid for the beneficiary for each month being
claimed by the Contractor for each beneficiary.
d. The total amount being claimed on the invoice.
4) The listing submitted in the thirteenth (13th) month following any month of
eligibility will be the final listing on which the Contractor is entitled to claims the
AIDS rate for that month of eligibility.
5) The Department will verify the Medi-Cal eligibility of each beneficiary for whom
the AIDS Rate is claimed and adjust the invoiced amounts to reflect any capitation
payments which have previously been made to the contractor for each beneficiary
prior to submission of the invoice required under subparagraph 3.
6) The MCEB will process the AIDS rate invoices, calculate payments and submit
the necessary paper work to the Department's accounting section within 25 days
of receipt of the invoice.
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County of Contra Costa Article IX
7) When the Department determines by subsequent review that a beneficiary for
whom capitation has been paid at the AIDS rate did not meet the definition of an
AIDS beneficiary in Article H, Section B, in a month for which the AIDS rate
was paid, the Department will recoup any amount improperly paid, by an offset
to the capitation payment. The Department will give written notices to the
contractor 30 days prior to any such offset.
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County of Contra Costa Article X
ARTICLE X -- SUBCONTRACTS
A. Subcontracts
1. All subcontracts will be in writing, and will be entered into pursuant to the
requirements of the Knox-Keene Health Care Services Plan Act of 1975 and
regulations promulgated thereunder, if licensed pursuant to that Act, and to
applicable federal laws and regulations.
2. A provider or management subcontract entered into by a plan which is not a
federally qualified HMO will become effective upon approval by the Department
in writing, or by operation of law where the Department has acknowledged
receipt of the proposed subcontract, and has failed to approve or disapprove the
proposed subcontract, and has failed to approve or disapprove the proposed
subcontract within 60 days of receipt. Subcontract amendments will be submitted.
to the Department for prior approval at least 30 days before the effective date of
any proposed changes governing compensation, services, or term. Proposed
changes which are neither approved nor disapproved by the Department, will
become effective operation of law 30 days after the Department has acknowledge
receipt or upon the date specified in the subcontract amendment, whichever is
later.
3. A subcontract will not be entered into if the compensation or other consideration
which the subcontractor will receive under the terms of the subcontractor is
determined by a percentage of the plan's payment from the Department. This
subsection will not be construed to prohibit subcontracts in which compensation
or other considerations is determined on a capitation basis.
4. A subcontractor providing any basic health care service to members will meet all
of the requirements of Chapters 3 and 4 of Subdivision 1, Division 3, of
Title 22, CCR, related to the services the subcontractor is required to perform.
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County of Contra Costa Article X
5. Subcontracts entered into by a plan and all information received in accordance
with this subsection will be public records on file with the Department. The
names of the officers and owners of the subcontractor, stockholders owning more
than 10 percent of the stock issued by the subcontractor and major creditors
holding more than 5 percent of the debt of the subcontractor will be attached to
the subcontract at the time the subcontract is presented to the Department.
6. Each subcontract submitted subject to Department approval pursuant to paragraph
2 will contain at least the elements required by paragraph 8 and the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor from the plan.
b. Specification of the services to be provided.
C. Specification that the subcontractor will be governed by and construed in
accordance with all laws, regulations, and contractual obligations of the
plan.
d. Specification that the subcontract amendments will become effective only
as set forth in paragraph 2.
e. Specification of the term of the subcontract including the beginning and
ending dates as well as methods of extension, renegotiation and
termination.
f. Subcontractor's agreement to submit reports as required by the contractor.
7. Subcontracts entered into by a plan which is a qualified HMO will be:
a. Exempt from prior approval by the Department.
b. Submitted to the Department upon request.
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8. Each subcontract will contain:
a. The subcontractor's agreement to make all of its books and records,
pertaining to the goods and services furnished under the terms of the
subcontract, available for inspection, examination or copying:
(1) By the Department, HHS, and the Department of Corporations.
(2) At all reasonable times at the subcontractor's place of business or
at such other mutually agreeable location in California.
(3) In a form maintained in accordance with the general standards
applicable to such book or record keeping.
(4) For a term of at least five years from the close of the
Department's fiscal year in which the subcontract was in effect.
b. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontracts from the plan.
C. Subcontractor's agreement to maintain and make available to the
Department, upon request, copies of all sub-subcontract and to ensure that
all sub-subcontracts are in writing and require that the sub-subcontractor:
(1) Make all applicable books and records available at all reasonable
times for inspection, examination, or copying by the Department.
(2) Retain such books and records for a term of at least five years
from the close of the Department's fiscal year in which the sub-
subcontract is in effect.
d. Subcontractor's agreement to notify the Department in the event the
agreement with the Contractor is amended or terminated. Notice is
considered given when properly addressed and deposited in the United
States Postal Services as first-class registered mail, postage attached.
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e. Subcontractor's agreement that assignment or delegation of the subcontract
will be void unless prior written approval is obtained from the
Department.
f. Subcontractor's agreement to hold harmless both the State and plan
members in the event the plan cannot or will not pay for services
performed by the subcontractor pursuant to the subcontract.
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ARTICLE XI -- FINANCIAL REPORTING
A. Annual Audit
The Contractor will have an annual audit performed in accordance with Section 14459,
W&I Code. Combined financial statements will be prepared in order to demonstrate the
financial position of the overall related health care delivery system when delivery of
health care or other services is dependent upon affiliates. Financial statements will be
presented in a form that clearly shows the financial position of the Contractor separately
from the combined totals. Interentity transactions and profits will be eliminated when
combined statements are prepared.
B. Certified Financial Statements
The Contractor will have separate certified financial statements prepared if the
independent accountant determines that preparation of combined statements is
inappropriate.
1. The independent accountant will state in writing his reasons for not preparing
combined financial statements.
2. The Contractor will provide supplemental schedules which clearly reflect all
interentity transactions and eliminations necessary to enable the Department to
analyze the overall financial status of the entire health are delivery system.
C. Inspection of Working Papers
The Contractor will authorize the independent accountant to allow representatives of the
Department, upon written request, to inspect any and all working papers related to the
preparation of the audit report.
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ARTICLE XII -- CONFIDENTIALITY OF DATA
A. Confidentiality of Information
Notwithstanding any other provision of this contract, names of persons receiving social
services are confidential and are to be protected from unauthorized disclosure in
accordance with Title 42, CFR, Section 431.300 et seq. and Section 14100.2, W&I Code
and regulations adopted thereunder. For the purpose of this contract, all information,
records, data, and data elements collected and maintained for the operation of the
contract and pertaining to members will be protected by the Contractor from
unauthorized disclosure.
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Cmunty of Contra Costa ATTACHMENT I
Contract No . 93-18608
NONDISCRIMINATION CLAUSE
(OCP - 1)
1. During the performance of this contract, contractor and its subcontractors will not
unlawfully discriminate against any employee or applicant for employment because of
race, religion, color, national origin, ancestry, physical handicap, medical condition,
marital status, age (over 40) or sex. Contractors and subcontractors will insure that the
evaluation and treatment of their employees and applicants for employment are free of
such discrimination. Contractors and subcontractors will comply with the provisions of
the Fair Employment and Housing Act (Government Code, Section 12900 et. seq.) and
the applicable regulations promulgated thereunder (California Code of Regulations,
Title 2, Section 7285.0 et seq.). The applicable regulations of the Fair Employment and
Housing Commission implementing Government Code, Section 12990, set forth in
Chapter 5 of Division 4 of Title 2 of the California Code of Regulations are incorporated
into this contract by reference and made a part hereof as if set forth in full, Contractor
and its subcontractors will give written notice of their obligations under this clause to
labor organizations with which they have a collective bargaining or other agreement.
2. This Contractor will include the nondiscrimination and compliance provision of this
clause in all subcontracts to perform work under the contract.
ATTACHMENT II
October 1, 1993
PREPAID HEALTH PLANS
RATE DEVELOPMENT
FISCAL YEAR
1993-94 Rates
PART 13. OVERVIEW OF THE RATE CALCULATION PROCESS
AND WORKSHEET
The purpose of the rate calculation process, as expl�fined in
this manual , is to develop a monthly rate per eligible Medi-Cal
beneficiary for a time period ' in the future called the Rate
Period. This year' s rate period is July- 1, 1991 to June 30,
1992 .
This process can be seen as a two step process with some
miscellaneous adjustments.
The first step in evaluating a given plan is to calculate
what rates would have been paid -in some past period. This must
take into consideration all the specific contract requirements,.
particularly as they differ from the entire fee-for-service (FFS)
group. It must consider all the demographic aspects of the
population being served, including aid code, • sex, age, and
geographic area. - _
The second step is to project this rate into the future.
There are two major considerations here: legislative changes and
trend. The first of these relates to bills that have been passed
or, are expected t'o be enacted. The latter of these is a
conglomerate of changes in physician practices, changes in Medi-
cal beneficiary practices, changes in hospital practices, and
anything else which might affect the cost of medical care.
Adjustments are then made for Child Health and Disability
Prevention (CHDP) , Short/Doyle, health insurance recoveries, stop
loss reinsurance, administration and. dental.
The Capitation Rate Worksheet, on page 7, shows how a single
capitation rate is calculated. A short line-by-line description
of this process follows. Each line number also refers to a
section .in Part C :which gives a more detailed explanation of the
adjustment.
At the top right of the worksheet, the Base Period and Rate
Period are shown. The base period refers to the first step in
the process, that is, calculating the *monthly cost per eligible
for a given period .in the past. - The rate period refers to the
period for which capitation payments will be made.
Note that rates are calculated for specific aid code
groupings and each of six different types of services, or vendor
code groupings .
The general methodology is to start with a dollar number and
multiply it by a series. of factors, each of which is rounded to
three decimal places. The Contract Cost and the Projected Cost
are each rounded to . cents .
-2-
Each numbered line is defined as follows:
1. Base Cost - These 'are the cost per person per eligible
month (CPPM) figures for each of six vendor code groupings.
CPPM figures are calculated on other worksheets for each of
the four geographic regions, and nine aid code groupings.
2 . Area Adjustments - This factor adjusts. the base costs to
specific counties or to specific plans that operate in Los
Angeles county. There are no adjustments on this line for
counties other than - Los Angeles, Alameda, . Contra Costa,
Orange, Riverside, San Bernardino, San 'Diego, San Francisco,
and Santa Clara. No adjustment means that a factor of 1.000
appears on the worksheet. : For example $6.23 x 1.000 =
$6 . 23 .
3 . Acle/Sex Adjustments — These adjustments are all specific to
the plan which is being rated. Based on age/sex factors
calculated for the entire State, a plan's age/sex mix in a -
given aid code grouping is used to calculate its specific -
age/sex factors. There is no adjustment if a plan averaged
less than 100 -eligibles per month in an aid code grouping
during the most recent available past year of data.
4 . Contract Adjustments - In many cases, a particular plan will
contractually exclude coverage of certain medical services.
These services will then be paid through the fee-for-service
(FFS) system, and the plan will therefore not be capitated
for these potential costs. Note that no factors on this
line are greater than 1. 000. This is because reduced
services imply a reduction in the capitation rate.
5 . Elicribility. Adjustments - This , section represents
adjustments to the base cost because the distribution of
eligible months by aid code in a plan (within an aid code
grouping) differs from the statewide FFS distribution.
'6 . Interest Offset - . This adjustment relates to the way the
-State pays out funds. On the average, it takes three to four
months before all the bills relating to a single service--are
paid under Medi-Cal FFS. Because money is paid out earlier
to capitated plans , the State loses interest. This
adjustment intends to make up for this loss by reducing the
capitation payment.
7 . Legislative Adjustments - This section evaluates the
financial impact of legislative changes on the FFS program.
In some instances, laws have already been passed, -and only
the financial affect must, be estimated. In other cases
legislation is only expected to occur, and in these cases
the expected f inancial impact may be tempered. only changes
which are included in the May 1991 Medi-Cal Estimate are
considered.
-3-
8 . Trend - This adjustment predicts the affect of all other
changes that may take place in the Medi-Cal population and
in the medical services area, including fee-for-service
(FFS) rate increases not covered by legislative adjustments.
9 . Medical Cost Adjustments - An additional amount is added to
the rate if A plan will cover services generally provided by
the Child Health and Disability Prevention (CHDP) or Short/
Doyle Mental Health (SDMH) programs. - If a plan is expected
to recover amounts from a Medi-Cal beneficiary's private
health coverage, then an amount is subtracted from the rate
for other health insurance.
lo. Stop Loss Reinsurance - After the FFS Medical Cost is
determined, a further adjustment is made for stop loss
reinsurance. This means the• State will pay costs for claims
from a single beneficiary once they exceed a certain amount
during the Rate Period. Since these are costs which the
plan will not have to pay, the rate must be reduced.
11. Administration Allowance --A flat dollar amount is allowed
for administrative expenses for each Medi-Cal eligible per
month, depending on the aid code grouping. Aid code
groupings which are expected to have higher claim costs
receive greater allowances. These amounts differ for PHPs
and PCCMs because the State continues to handle certain
claims under the PCOM arrangement.
12 . Percent of Fee-for-Service Equivalent Cost Payable - The
total FFS Equivalent Cost is multiplied by a percentage to
get the Initial Capitation Rate. This year the percentage
has been set at 97% for the PHPs 95% and for the PCCMs.
13 . Dental Coverage - This adjustment is made only when a plan
elects to cover dental services. The amount covers these
services plus an administrative component.
-4-
' CAPITATION RATE WORKSHEET Date: 3/17/1993
Base Period: FT 88/89
Aid Group: Public Assistance Aged Rate Period: 17/92-9/93
County: Contra Costa Base: North Canities
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL
1. Base Cost 7.03 23.13 34.79 7.52 40.34 5.07 5117-88
2. Area Adjustments _962 1.151 .933 1.247 .976 :898
3. Age/Sex Adjustments .998 1.019 1.015 1.002 1.107 1.025
4. Contract Adjustments
a. Hemo, Maj Org, LTC .998 1.000 1.000 1.000 .278 1.000
b. AIDS 1.000 1.000 1.000 1.000 1.000 1.600
c. Procedures 1.000 1.000 1.000 1.000 1.000 1.000
5. Eligibility Adjustments
a. Aid Codes 1.002 .988 .998 .996 .997 .963
b. Medicare 1.052 .997 1.042 1.000 1.005 1.012
6. Interest Offset .982 .992 .968 .975 .989 .983
CONTRACT COST FY 88/89 $6.97 $26.51 $33.16 $9.12 $12.01 $4.47 $92.24
7. Legislative Adjustments
a. .Fees 3Q/89 1.000 1.000 1.000 1.000 1.000 1.000
4Q/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
3Q/90 1.000 1.000 1.000 1..000 1.072 1.000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1.000 1.000
b. Benefits 30/89 .998 .996 1.023 1.033 .998 .998
46/89 1.015 .995 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.004 1.038
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
2Q/91 1.000 1.000 1.000 1.007 1.000 1.007
8. Trend 1/89-1/91 .974 1.238 1.143 .251 1.075 1.875
PROJECTED COST FY 90/91 $6.88 $32.52 538.93 $2.41 S13-87 $8.37 $102.98
9. Medical Cost Adjustments
a. CHOP .00
b. Short/Doyle Mental Health .79 i
c. Health Insurance Recoveries ( .31)
FEE-FOR-SERVICE MEDICAL COST 5103.46
10. Stop Loss Reinsurance at 100,000 is .17. ( _09)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE $103.37
11. Administration Allowance 4.62
TOTAL FEE-FOR-SERVICE EQUIVALENT COST $107,99
12. Percent of Fee-for-Service Equivalent Cost Payable 97-0%
INITIAL CAPITATION RATE 5104.75
13. Dental Coverage 9.09
FINAL CAPITATION RATE 5113.84
-5-
CAPITATION RATE WORKSHEET Date: 3/17/1993
Base Period: FY 88/89
Aid Group: Public Assistance Family Rate Period: 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL
1. Base Cost 13.93 4.29 32.30 7.52 .04 4.05 562.13
2. Area Adjustments 1.052 .980 1.046 1.131 1.000 _ _999
3. Age/Sex Adjustments 1.043 .975 1.032 1.027 1.000 1.011
4. Contract Adjustments
a. Hemo, Maj Org, LTC .999 1.000 1.000 1.000 .580 1.000
b. AIDS 1.000 1.000 1.000 1.000 1.000 1.000
c. Procedures 1.000 1.000 1.000 1.000 1.000 1.000
5. Eligibility Adjustments
a. Aid Codes 1.006 .982 1.026 1.022 1.000 .954.
b. Medicare 1.000 1.000 1.000 - 1.000 1.000 1.000
6. Interest Offset .985 .992 .980 .985 .990 .985
CONTRACT COST FY 88/89 $15.13 $3.99 $35.06 38.79 3.02 $3.84 566.83
7. Legislative Adjustments _
a. Fees 30/89 1.000 1.000 1.000 1.000 1.000 1.000
40/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1.000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1.000 1.000
b. Benefits 30/89 1.048 .996 1.023 1.085 .998 .998
40/89 1.015 .995 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.004 1.038
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1.000 1-007
8. Trend 1/89-1/91 1.053 1.118 1.215 1.131 1.000 1.604
PROJECTED COST FY 90/91 516.95 $4.42 $43.75 $11.01 S.02 56.15 382.30
9. Medical Cost Adjustments
a. CHDP 2.02
b. Short/Doyle Mental Health 2.88
c. Health Insurance Recoveries ( .04)
FEE-FOR-SERVICE MEDICAL COST $87.16
10. Stop Loss Reinsurance at 100,000 is .8% ( _66)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE 586.50
11. Administration Allowance 3.08
TOTAL FEE-FOR-SERVICE EQUIVALENT COST $89.58
12. Percent of Fee-for-service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE 586-89
13. Dental Coverage 9.09
FINAL CAPITATION RATE $95.98
-6-
• . CAPITATION RATE WRKSHEET Date: 3/17/1993
Base Period: FY 89/89
Aid Group: Public Assistance Disabled Rate Period: 4009e-'Y7"
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL
1. Base Cost 23.40 34.66 100.24 15.78 32.86 18.81 5225.75
2. Area Adjustments .907 1.036 .887 1.098 .549 _ :991
3. Age/Sex Adjustments .956 1.077 .898 .993 1.001 .898
4. Contract Adjustments
a. Hemo, Maj Org, LTC .992 1.000 1.000 .999 .140 1.000
b. AIDs .989 .976 .966 .958 .999 .491
c. Procedures 1.000 1.000 1.000 1.000 1.000 1.000
5. Eligibility Adjustments
a. Aid Codes 1.008 .995 1.010 1.001 .998 .985
b. Medicare .920 1.008 .916 --'.973 .960 .970
6. Interest Offset .982 .991 .976 .979 .990 .981
CONTRACT COST FY 88/89 $18.13 $37.52 $69.64 $15.70 $2.40 515.55 $158.94
7. Legislative Adjustments
a. Fees 30/89 1.000 1.000 1.000 -1.000 1.000 1.000
40/89 1.000 1.000 1.000 1.0001 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1.000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1.000 1.000
b. Benefits 30/89 .998 .996 1.023 1.033 .998 .998
40/89 1.015 .995 1.000 1.000 1.000 1.000 _
10/90 1.000 1.000 1.000 1.000 1.004 1.038
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1.000 1.007
8. Trend 1/89.1/91 1.009 1.200 1.165 .841 1.142 1.302
PROJECTED COST FY 90/91 $18.53 $44.62 $83.33 $13.93 52.94 520.21 $183.56
9. Medical Cost Adjustments
a. CHDP .06
b. Short/Doyle Mentat Health 25.24
c. Health Insurance•Recoveries ( .54)
FEE-FOR-SERVICE MEDICAL COST $208.32
10. Stop Loss Reinsurance at 100,000 is 1.6% ( 2.89)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE 5205.43
11. Administration Allowance 6.76
TOTAL FEE-FOR-SERVICE EQUIVALENT COST 1212.19
12. Percent of Fee-for-Service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE 1205.82
13. Dental Coverage 9.09
FINAL CAPITATION RATE 1214-91 '
eCAPITATION RATE 4JORKSHEET Dat c: 3/17/1993
Base Period: FY 88/89
Aid Group: Medically Needy No Share - Aged Rate Period: 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL
1. Base Cost 16.14 17.79 69.96 12.09 26.16 12.87 5155.01
2. Area Adjustments 1.000 1.000 1.000 1.000 1.000 _ 1.000
3. Ase/Sex Adjustments 1.000 7.000 1.000 1.000 1.000 1.000
4. Contract Adjustments
a. Hemo, Maj Org, LTC .991 1.000 1.000 .999 .482 1.000
b. AIDS 1-000 1.000 1.000 1-000 1.000 1.600
c. Procedures 1.000 1.000 1.000 1-000 1-000 1-000
5. Eligibility Adjustments
a. Aid Codes 1.000 1.000 1.000 1.000 1.000 1-000
b. Medicare 1.000 1.000 1.000 1.000 1-000 1.000
6. Interest Offset .969 .991 .963 .967 .986 .975
CONTRACT COST FY 88/89 $15.50 $17.63 ' $67.37 Sit-68 $12.43 • S12.55 5137.16
7. Legislative Adjustments
a. Fees 30/89 1.000 1.000 1.000 1.000 1.000 1.000 -
40/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000,
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1-072 1-000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1.000 1-000
b. Benefits 30/89 .998 .996 1.023 . 1.033 .998 .998
40/89 1.015 .995 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.004 1.038
24/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1.000 1.007
8. Trend 1/89-1/91 .981 1.233 1.143 .592 1.049 1.339
PROJECTED COST FY 90/91 $15.40 621.54 $79.09 $7.29 S14.01 516.78 S154.11
9. Medical Cost Adjustments
a. CHOP .00
b. short/Doyle Mental Health 1.27 i
c. Health Insurance'Recoveries ( -67)
FEE-FOR-SERVICE MEDICAL COST $154.71
10. Stop Loss Reinsurance at 100,000 is .0% .00
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE $154.71
11. Administration Allowance 5.17
TOTAL FEE-FOR-SERVICE EQUIVALENT COST S159.88
12. Percent of Fee-for-service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE 5155.08 .
13. Dental Coverage 9.09
FINAL CAPITATION RATE $164.17
CAPITATION RATE WORKSHEET Date: 3/17/1993
Base Period: FY 88/89
Aid Group: Medically Needy No Share - Family Rate Period: 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL
1. Base Cost 21.35 4.62 73.57 12.31 .31 8.36 S120.52
2. Area Adjustments 1.028 1.068 .898 1.190 1.000 - 1:121
3. Age/Sex Adjustments .914 .961 .891 .942 1.000 .950
4. Contract Adjustments
a. Hemo, Maj Org, LTC .998 1.000 1.000 1.000 .491 1.000
b. AIDS 1.000 1.000 1.000 1.000 1.000 1.000
c. Procedures 1.000 1.000 1.000 1.000 1.000 1.000
5. Eligibility Adjustments
a. Aid Codes 1.000 1.000 1.000 1.000 1.000 1.000
b. Medicare 1.000 1.000 1.000 -1.000 1.000 1.000
6. Interest Offset .980 .990 ..970 .978 .985 .982
CONTRACT COST FY 88/89 $19.62 $4.69 $57.10 513.50 S.15 $8.74 $103.80
7. Legislative Adjustments
a. Fees 30/89 1.000 1.000 1.000 1.000_ 1.000 1.000
40/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1.000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1400 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1.000 1.000
b. Benefits 30/89 1.048 .996 1.023 1.085 .998 .998
40/89 1.015 .995 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.004 1.038
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1.000 1.007
S. Trend 1/89-1/91 1.032 1.146 1.252 1.066 1.000 1.174
PROJECTED COST FY 90/91 $21.54 $5.33 $73.43 $15.94 $.16 $10.24 S126.64
9. Medical Cost Adjustments
a. CHDP 1.82
b. Short/Doyle Mental Health 2.51
c. Health Insurance Recoveries ( _21)
FEE-FOR-SERVICE MEDICAL COST 5130.76
10. Stop Loss Reinsurance at 100,000 is _8X ( 1.01)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE $129.75
11. Administration Allowance 4.05
TOTAL FEE-FOR-SERVICE EQUIVALENT COST $133.80
12. Percent of Fee-for-Service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE 5129.79
13. Dental Coverage 9.09
FINAL CAPITATION RATE 5138.88
i
CAPITATION RATE WORKSHEET Date: 3/17/1993
Base Period: FT 88/89
Aid Group: Medically Needy No Share - Disabled Rate Period: 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL .
1. Base Cost 50.77 41.01 637.53 43.09 26.17 36-64 $835.21
2. Area Adjustments 1.000 1.000 1.000 1.000 1.000 - 1:000
3.•Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000
4. Contract Adjustments
a. Hemo, Maj Org, LTC .969 1.000 1.000 .998 .491 1.000
b. AIDs .978 .741 .919 .828 .979 1.004
c. Procedures 1.000 1.000 1.000 1.000 1.000 1-000
5. Eligibility Adjustments
a. Aid Codes 1.000 1.000 .999 .999 1.000 1.001
b. Medicare 1.000 1.000 1.000 -" 1.000 1.000 1.000
6. Interest offset .968 .985 .958 .971 .985 .973
CONTRACT COST FY 88/89 $46.57 $29.93 $560.72 $34.54 $12.39 $35.83 5719.98
7. Legislative Adjustments _
a. Fees 30/89 1.000 1.000 1.000 1.000 1.000 1.000
40/89 1.000 1.000 1.000 ' 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1.000
40/90 1.000 1.000 1.000 7.000 1.000 1.000
1Q/91 1.000 1.000 1.000 1.000 1.000 1.000
2Q/91 1.000 1.000 1.000 1.000 1.000 1.000
b. Benefits 30/89 .998 .996 1.023 1.033 .998 .998
40/89 1.015 .995 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.004 1.038
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1-000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1.000 1.007
8. Trend 1/89-1/91 1.048 1.204 1.273 1.042 1.209 1.161
PROJECTED COST FY 90/91 $49.44 $35.71 $733.13 537.96 $16.09 $41.53 $913.86
9. Medical Cost Adjustments
a. CHDP _01
b. Short/Doyle Mental Health 22.48
c. Health Insurance Recoveries ( 1.76)
FEE-FOR-SERVICE MEDICAL COST S934_59
10. Stop Loss Reinsurance at 100,000 is 1.6% ( 14.36)'
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE $920.23
11. Administration Allowance 16.50
TOTAL FEE-FOR-SERVICE EQUIVALENT COST $936.73
12. Percent of Fee-for-Service Equivalent Cost Payable 97.07.
INITIAL CAPITATION RATE $908.63
13. Dental Coverage 9.09
FINAL CAPITATION RATE S917.72
-1Q-
Y
J u
CAPITATION RATE WORKSHEET Date: 3/17/1993
Base Period: FY 88/89
Aid Group: Medically Indigent Children Rate Period: 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm HIP HOP LTC Other TOTAL
1. ease Cost 16.18 3.04 101.40 10.13 .63 5.16 $136-54
2. Area Adjustments 1.000 1.000 1.000 1.000 1.000 _ 1.000
3. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1-000
4. Contract Adjustments
a. Hemo, Maj Org, LTC .997 1.000 1.000 .999 .292 1.000
b. AIDS 1.000 1.000 1.000 1.000 1.000 1.600
c. Procedures 1.000 1.000 1.000 1.000 1.000 1,000
5. Eligibility Adjustments
a. Aid Codes 1.009 .945 1.023 1.026 1.000 .893
b. Medicare 1.000 1.000 1.000 - 1.000 1.000 1-000
6. Interest Offset .979 .988 .969 _976 .985 .980
CONTRACT COST FY 88/89 $15.93 $2.84 $100.52 510.13 S.18 $4.52 $134.12
7. Legislative Adjustments
a. Fees 3Q/89 1.000 1.000 1.000 1.000 1.000 1.000
40/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1-000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1.000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1..000 1.000 1.000
b. Benefits 30/89 .998 .996 1.023 1.033 .998 .998
40/89 1.015 .995 1.000 1.000 1.000 1-00d
10/90 1,000 1.000 1.000 1.000 1,004 1.038
20/90 1,000 1.000 1.000 1.000 1.000 1.000
30/90 1,000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1,000 1.000 1.000 1.000 1.000
1Q/91 1,000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1,000 1.007
8. Trend 1/89-1/91 .972 1.061 1.339 1.086 1.000 1.167
PROJECTED COST FY 90/91 $15.68 $2.99 $138.24 $11.60 S.19 $5.27 S173.97
9. Medical Cost Adjustments
a. CHOP 3.19
b. Short/Doyle Mental Health 4.96
c. Health Insurance Recoveries ( -13)
FEE-FOR-SERVICE MEDICAL COST 5181.99
10. Stop Loss Reinsurance at 100,000 is 2.2% ( 3.82)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE 5178.17
11. Administration Allowance 3.66
TOTAL FEE-FOR-SERVICE EQUIVALENT COSI• $181.83
12. Percent of Fee-for-service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE 5176.38
13. Dental Coverage 9.09
FINAL CAPITATION RATE $185-47
-11-
CAPITATION RATE WORKSHEET Date: 3/17/1993
Base Period: FY 89/89
Aid Croup: Medically Indigent Adults - Rate Period- 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =____> Phys Pharm' HIP HOP LTC Other TOTAL.
1, Base Cost 100.72 3.25 325.74 41.21 .00 29.77 3500.69
2. Area Adjustments 1.000 1.000 1.000 1-000 1.000 _ 1:000-
3. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000
4, Contract Adjustments
a• Remo, Maj Org, LTC 1.000 1.000 1.000 1.000 _999 1.000
b. AIDS 1.000 1.000 1.000 1-000 1.000 1.100
c, Procedures 1.000 1.000 1.000 1.000 1.000 1.000
5. Eligibility Adjustments
a. Aid Codes 1.000 1.000 1.000 1.000 1.000 1.000
b. Medicare 1.000 1.000 1.000 -• 1-000 . 1.000 1.000
6. Interest Offset .977 .988 .972 .971 .985 .980
CONTRACT. COST FY 88/89 $98.40 $3.21 $316.62 $40.01 $29.17 $487.41
7. Legislative Adjustments -
a. Fees 30/89 1.000 1.000 1.000 1.000 1_000 1.000
40/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000' 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1-000
40/90 1.000 1.000 1.000 1,000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1.000 1.000
b. Benefits 30/89 1.048 .996 1.023 1.085 _998 .998
40/89 1.015 .995 1.000 1,000 1.000 1.000 _
10/90 1.000 1.000 1.000 1.000 1.004 1.038
20/90 1-000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.004 1.014 1.000 .957
40/90 1.000 1.000 1.000 1.000 1.000 1.000 .
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.007 1.000 1.007
B. Trend 1/89-1/91 1.081 1.272 1.267 1.085 1.000 1.370
PROJECTED COST FY 90/91 $113.15 $4.05 $412.03 $48.09 339.90 $617.22
9. Medical Cost Adjustments
a. CHDP
1.56
b. Short/Doyle Mental Health 8.03
c. Health Insurance Recoveries ( .93)
FEE-FOR-SERVICE MEDICAL COST $625-88
10. Stop Loss Reinsurance at 100,000 is .1X ( ,62)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE 5625.26
11. Administration Allowance 10.95
TOTAL FEE-FOR-SERVICE EQUIVALENT COST 5636.21
12. Percent of Fee-for-Service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE S617.12
13. Dental Coverage 9.09
FINAL CAPITATION RATE 1626.21
_12_ •
/t
♦.A.
CAPITATION FATE WORKSHEET Date. 3/17/1993
Base Period: FY 83/89
Aid Group: AIDS Rate Period: 11/92-9/93
County: Contra Costa Base: North Counties
Contract: 45 Contra Costa
Services =-___> Phys Pharm HIP HOP LTC Other TOTAL
1. Base Cost $83.59 $316.78 $1,478.16 5140.68 S14.81 582-39 $2,116.41
2. Area Adjustments 1.000 1.000 1.000 1.000 1.000 _ 1.000
3. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1-000
4. Contract Adjustments
a. Hemo, Maj Org, LTC 1.000 1.000 1.000 1.000 0 1.000
b. AIDS 1.000 1.000 1-000 1.000 1-000 1.600
c. Procedures 1.000 1.000 1.000 1.000 1.000 1.000
5. Eligibility Adjustments
a. Aid Codes 1.000 1.000 1.000 1.000 1.000 1.000
b. Medicare 1.000 1.000 1.000 • 1.000 1.000 1.000
6. Interest Offset .975 _978 .966 .973 .982 .972
CONTRACT COST FY 88/89 $81-50 $309.81 $1,427.90 $136.88 $2.04 580.08 $2,038.21
7. Legislative Adjustments _
a. Fees 30/89 1.000 1.000 1.000 1.000, 1.000 1.000
40/89 1.000 1.000 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.000 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.072 1.000
40/90 1-000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20/91 1.000 1.000 1.000 1.000 1-000 1.000
b. Benefits 30/89 .998 .996 1.023 1.033 .998 .998
40/89 1.015 .987 1.000 1.000 1.000 1.000
10/90 1.000 1.000 1.000 1.000 1.004 1.000
20/90 1.000 1.000 1.000 1.000 1.000 1.000
30/90 1.000 1.000 1.000 1.000 1.000 1.000
40/90 1.000 1.000 1.000 1.000 1.000 1.000
10/91 1.000 1.000 1.000 1.000 1.000 1.000
20191 1.000 1.000 1.000 1.007 1.000 1.007
8. Trend 1/89-1/91 .855 1.320 .855 1.102 1.000 1.155
PROJECTED COST FY 90/91 $70.59 . $402.02 $1,248.93 5156.91 $2.19 $92.95 51,973.59
9. Medical Cost Adjustments
a. CHDP .00
b. Short/Doyle Mental Health .00
c. Health Insurance Recoveries -.54
FEE-FOR-SERVICE MEDICAL COST $1,973.05
10. Stop Loss Reinsurance at 100,000 is _7X ( 13.80)
FEE-FOR-SERVICE MEDICAL AFTER REINSURANCE $1,959.25
11. Administration Allowance 27.99
TOTAL FEE-FOR-SERVICE EQUIVALENT COST $1,987.24
12. Percent of Fee-for-Service Equivalent Cost Payable 97.0%
INITIAL CAPITATION RATE 51,927.62
13. Dental Coverage 9-09
FINAL CAPITATION RATE 51,936.71
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