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3.
Service Hours The health advice service will be operated 24 hours a day, 7 days a week. All other services shall be provided during normal Contractor working hours, Monday through Friday, excluding national holidays.
4.
Project Representatives A. The project representatives during the term of this agreement will be: Department of Health Care Services Luis Rico, Chief Telephone: (916) 449-5240 Fax: (916) 552-9244 E-mail: Luis.Rico@dhcs.ca.gov B. Direct all inquiries to: Department of Health Care Services Systems of Care Division Attention: Luis Rico Mail Station Code 4517 1501 Capitol Avenue P.O. Box 997419 Sacramento, CA 95899-7419 Telephone: (916) 449-5240 Fax: (916) 552-9244 E-mail: Luis.Rico@dhcs.ca.gov Innovative Resource Group, LLC dba APS Healthcare Midwest Attention: Richard Surles 44 South Broadway, Suite 1200 White Plains, NY 10601 Telephone: (800) 305-3720 x3119 Fax: (914) 288-4605 E-mail: publicsector@apshealthcare.com Innovative Resource Group, LLC dba APS Healthcare Midwest Richard Surles, Chief Development Officer Telephone: (800) 305-3720x3119 Fax: (914) 288-4605 E-mail: publicsector@apshealthcare.com
C. Either party may make changes to the information above by giving written notice to the other party. Said changes shall not require an amendment to this agreement. D. All notices to be given under this Contract will be in writing and will be deemed given when mailed to DHCS or the Contractor: Department of Health Care Services Attention: Luis Rico Mail Station 4517 1501 Capitol Avenue P.O. Box 997413 Sacramento, CA 95899-7419 Innovative Resource Group, LLC dba APS Healthcare, Inc. Attn: Richard Surles 44 South Broadway, Suite 1200 White Plains, NY 10601
2. Members Records Contractor shall develop, implement and maintain written procedures pertaining to Members records that address the following areas: a. Collection, processing, maintenance, storage, retrieval, identification, and distribution; b. Ensuring that Members records are protected and confidential in accordance with all Federal and State laws; c. Release of information; and d. Ensuring the maintenance of Members records in a legible, current, detailed, organized and comprehensive manner (records may be electronic or paper copy).
e. All Medi-Cal beneficiaries receiving full scope Medi-Cal benefits without a share of cost requirement who meet the qualifications noted above will be considered a Potential Member for the CCMP-SMI, except those who: 1) Have restricted/emergency only Medi-Cal; 2) Are Medicare eligible; 3) Have other insurance that provides comparable CCMP-SMI services (e.g., Medi-Cal Managed Care); 4) Reside in nursing facilities (NF); (in the most recent sic (6) months prior to enrollment); 5) Reside in all levels of Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) in the most recent 6 months prior to enrollment; 6) Have a Medi-Cal eligibility period that is only retroactive; 7) Participate in Medicaid waiver programs, including Home and Community Based, Freedom of Choice and Research and Demonstration waivers; 8) Are enrolled in a hospice program: or 9) Have an HIV diagnosis on a Medi-Cal claim since June 1, 2005 f. As part of the enrollment process noted below, DHCS will screen out MediCal beneficiaries who are not eligible for the program by generating a list of Potential Members according to the actual number of Members will be less than the number of Potential Members that opt-out of the CCMP-SMI and other data irregularities that are not within the control of DHCS. Referrals to the CCMP-SMI from other sources such as self, caregiver, family member, guardian or provider must be approved by DHCS prior to enrollment by the contractor.
g. The minimum number of Members that will be enrolled in the CCMP-SMI are based on the quotas as described in provision G.2 above. The maximum number of Members enrolled in the CCMP-SMI will be limited by the availability of funding. If membership exceeds CCMP-SMI availability, DHCS will develop and implement a process for an enrollment waiting list. h. A Member who, during the time of CCMP-SMI membership, enters a nursing facility for a short-term stay of thirty (30) days or less will not be disenrolled except at the Members request.
x) y) f.
Coordination/Continuity of Care Contractor shall develop and implement policies and procedures related to establishing relationships, developing referral processes, and sharing information with the Provider/PCP, discharge planners, facility staff, Specialists, and State or Community agencies to enable Members to access needed services and ensure continuity of care. The Contractor will ensure continuity of care in collaboration with the Provider/PCP by: 1) Coordinating care so that an ongoing course of treatment is not interrupted or delayed due to the change in new providers; 2) Assisting with the transfer of medical record information to new providers in a timely fashion; 3) Assisting with development and implementation of a patient/disease registry capable of being shared with other providers; 4) Monitoring the referral and follow-up of Members in need of specialty care and routine health care services; 5) Documentation of referral and follow-up services in Members record 6) Documentation in Members record of emergency medical encounters with the appropriate follow-up as medically indicated; 7) Documentation and follow-up in Members record of planned health care services; and
k. Collaboration with other disease and/or care management programs to ensure services provided to Members are complementary and not duplicative (e.g. California Mental Health Care Management Program [CalMEND]). 4. Health Advice Service The Contractor must offer a toll-free telephonic health advice service staffed by health care professionals, as defined in California Business and Professions Code Section 4999.2. The service must be operated twenty four (24) hours per day, seven days a week. Operators of the advice service will provide general and personalized health care information. The advice service will also provide education and assistance for CCMP-SMI Members and/or their caregivers. This line must be operated in accordance with current managed care program rules for comparable advice services, including provisions for interpreter services (Business and Professions Code Section 4999.2 and 4999.7 and Section 1348.8 of the Health and Safety Code). The Contractor must develop and implement a timely method of communicating the Member telephone contact information with the Members care manager and ensure the advice service is operated in an efficient and effective manner. 5. Member Education a. Contractor shall implement and maintain a health education system that includes programs, services, functions, and resources necessary to provide health education, health promotion and patient education for all Members.
H.
Member Services - Access and Availability The Contractor shall establish accessibility standards, which include, but are not limited to, the following: 1. Access Requirements a. Assisting Members in finding a medical home b. Telephone Procedures - Contractor shall maintain procedures for triaging Members telephone calls, providing telephone advice and accessing telephone interpreters. c. Contractor shall ensure that all non-English-speaking, or limited English proficient (LEP) CCMP-SMI Members receive 24-hour oral interpreter services, either through interpreters or telephone language services. Contractor shall arrange or provide, at minimum, the following linguistic services at no cost to the CCMP-SMI Members:
g. Exam table; h. Auxiliary aides and services; and i. Public transportation access.
4. Changes in Availability or Location of DM Services Contractor shall provide notification to DHCS sixty (60) calendar days prior to making any substantial change in the availability or location of services to be provided under this Contract. In the event of an emergency or other unforeseeable circumstance, Contractor shall provide notice of the emergency or other unforeseeable circumstance to DHCS as soon as possible.
Provider Services
1. Provider Education Contractor shall provide education and training to Provider/PCP to include, but not be limited to, the following: a. Information on all Member rights, Member services, and the right to actively participate in health care decisions; b. Use of evidence-based practice guidelines; c. Resource tools developed by the Contractor to facilitate the use of evidencebased practice guidelines by the Provider/PCP; d. Evaluation and appropriate treatment or referral of mental health issues; e. The Medi-Cal Treatment Authorization Request (TAR) process; f. Identification and utilization of community resources; and
g. Disability cultural competency and sensitivity training, including information about: 1) Various types of chronic conditions and disabilities prevalent among Medi-Cal beneficiaries; 2) Awareness of personal prejudices; 3) Legal obligations to comply with the Americans with Disabilities Act (ADA); 4) Scope of benefits, including how to refer people to services covered by other state agencies; 5) Definitions and concepts such as communication access, medical equipment access, physical access, and access to programs; and 6) The types of barriers that adults with physical, sensory, communication disabilities, developmental or mental health needs face in the health care arena and the resulting access and accommodation needs. 2. Provider Feedback Contractor shall develop and implement system(s), which will provide information to the Provider/PCP relating to Members adherence to the ITP. Contractor shall employ feedback techniques to the Provider/PCP to improve the quality and appropriateness of the care provided to the Member. J. Implementation Plan and Deliverables The Implementation Plan and Deliverables section describes DHCS requirements for specific deliverables, activities, and timeframes that the Contractor must complete during the Implementation Period before beginning operations.