AZ

"35.  HOSPITAL SUBCONTRACTING AND REIMBURSEMENT...
The Pilot as defined by AHCCCS Rule R9-22-718 requires hospital subcontracts to be negotiated between health plans in Maricopa and Pima counties and hospitals to establish reimbursement levels, terms and conditions.  Subcontracts shall be negotiated by the Contractor and hospitals to cover operational concerns, such as timeliness of claims submission and payment, payment of discounts or penalties, legal resolution, which may, as an option, include establishing arbitration procedures..."  Arizona Contract, page 37.

"51. SUBCONTRACTS...
Subject to such conditions, any function required to be provided by the Contractor pursuant to this contract may be subcontracted to a qualified person or organization...

All subcontracts entered into by the Contractor are subject to prior review and approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by reference the terms and conditions of this contract.  The following subcontracts shall be submitted to AHCCCSA Contracting Office for prior approval at least 30 days prior to the beginning date of the subcontract:
  a. Automated data processing
  b. Third-party administrators
  c. Management Services  (See also Section D, Paragraphs 53 & 54)
  d. Model subcontracts
  e. Capitated or other risk subcontracts requiring claims processing by the subcontractor must be submitted to AHCCCSA, Office of Managed Care…

These and any other exceptions to this requirement must be approved by AHCCCS Office of Managed Care.  Each subcontract must contain verbatim all the provisions of Attachment A, Minimum Subcontract Provisions.  In addition, each subcontract must contain the following: ...
  d. The amount, duration and scope of medical services to be provided, and for which compensation will be paid...
  f. The specific duties of the subcontractor relating to coordination of benefits and determination of third-party liability.
  g. A provision that the subcontractor agrees to identify Medicare and other third-party liability coverage and to seek such Medicare or third party liability payment before submitting claims to the Contractor/ Contractor.
  h. A description of the subcontractor's patient, medical and cost record keeping system.
  i. Specification that the subcontractor shall cooperate with quality assurance programs and comply with the utilization control and review procedures specified in 42 CFR Part 456, as implemented by AHCCCSA.
  j. A provision stating that a merger, reorganization or change in ownership of a subcontractor that is related to or affiliated with the Contractor shall require a contract amendment and prior approval of AHCCCSA.
  k. Procedures for enrollment or re-enrollment of the covered population.
  l. A provision that the subcontractor shall be fully responsible for all tax obligations, Worker's
Compensation Insurance, and all other applicable insurance coverage obligations which arise under this subcontract, for itself and its employees, and that AHCCCSA shall have no responsibility or liability for any such taxes or insurance coverage.
m. A provision that the subcontractor must obtain any necessary authorization from the Contractor or AHCCCSA for services provided to eligible and/or enrolled members.
  n. A provision that the subcontractor must comply with encounter reporting and claims submission requirements as described in the subcontract.

52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and AHCCCSA for specialized hospital and medical services...

53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation plans must be approved in advance by AHCCCSA Contracting Office as described in Section D, Paragraph 51, Subcontracts…"  Arizona Contract, pages 49-50.

"ATTACHMENT A:   MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract.]
1.  EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES...
2.  RECORDS AND REPORTS...
3.  LIMITATIONS ON BILLING AND COLLECTION PRACTICES...
4.  ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES...
5.  APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS...
6.  WARRANTY OF SERVICES...
7.  SUBJECTION OF SUBCONTRACT...
8.  AWARDS OF OTHER SUBCONTRACTS...
9.  INDEMNIFICATION BY SUBCONTRACTOR...
10.  MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES...
11.  COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS...
12.  SEVERABILITY...
13.  VOIDABILITY OF SUBCONTRACT...
14.  CONFIDENTIALITY REQUIREMENT...
15.  GRIEVANCE PROCEDURES...
16. TERMINATION OF SUBCONTRACT...
17.  PRIOR AUTHORIZATION and UTILIZATION REVIEW...
18.  NON-DISCRIMINATION REQUIREMENTS...
19.  COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION...
20.  CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION...
21.  CERTIFICATION OF COMPLIANCE  -  ANTI-KICKBACK and LABORATORY TESTING...
22.  CONFLICT IN INTERPRETATION OF PROVISIONS...
23.  ENCOUNTER DATA REQUIREMENT...
24.  CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988...
25.  INSURANCE...
26.  FRAUD AND ABUSE..."  Arizona Contract, pages A1-A6.

AZBH

"18.  STAFF REQUIREMENTS...
ADHS shall establish minimum staffing requirements for its subcontracted RBHAs.  ADHS shall include these staffing requirements in contract...

20.  PROVIDER NETWORK REQUIREMENTS...
ADHS is responsible for provider network requirements, although the performance of these functions may be delegated to the subcontracted RBHAs.

Network Development:  ADHS shall establish and maintain a statewide network of subcontractors and providers that is sufficient to provide all behavioral health covered services under this contract...

ADHS shall require that its subcontracted RBHAs monitor timely accessibility and provision of crisis services for Title XIX and Title XXI members requiring emergency services.  ADHS shall require its subcontracted RBHAs to take corrective action when service gaps are identified.  In assessing the sufficiency of the provide network, ADHS shall include utilization of available appointment standard data, problem resolutions, reported member concerns, grievance and appeal data, member satisfaction surveys and random provider appointment availability surveys."  Arizona Behavioral Health Contract, pages 20-21.

"3.  SUBCONTRACTED RBHA DISCLOSURE AND RELATED PARTY TRANSACTIONS STATEMENTS
ADHS shall obtain ownership and control and related party transaction information from all its subcontracted RBHAs.  This disclosure information will be evaluated by ADHS for reasonableness, potential adverse impact on the subcontracted RBHA, and any significant conflict of interest...

9.  CASE FILE REVIEW
ADHS shall require that each of its subcontracted RBHAs conduct an annual Case File Review of the care provided to Title XIX and Title XXI members by the subcontracted RBHA.  ADHS shall require that reviews be conducted on a sample of member records for each population served for each geographic service area based on a sampling methodology approved by AHCCCS…"  Arizona Behavioral Health Contract, Attachment C, pages C4 -C5.

CA

"3.9 NONDISCRIMINATION CLAUSE COMPLIANCE
A. During the performance of this Contract, Contractor and its subcontractors will not unlawfully discriminate, harass, or allow harassment, against any employee or applicant for employment...

B. The Contractor will include the nondiscrimination and compliance provisions of this clause in all Subcontracts to perform work under this Contract."  California Contract, pages 18-19.

"3.28  SUBCONTRACTS
The Contractor may elect to enter into Subcontracts with other entities in order to fulfill the obligations of the Contract.  In doing so, Contractor shall meet the subcontracting requirements as stated in Title 22, CCR, Section 53867 and this Contract.

3.28.1 Knox-Keene and Regulations
All Subcontracts shall be in writing, and shall be entered into in accordance with the requirements of the Knox-Keene Health Care Services Plan Act of 1975...

3.28.2 Subcontract Requirements
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 DHS, DHHS, DOJ, and DOC...

C. Subcontractor's agreement to maintain and make available to DHS, upon request, copies of all sub-subcontracts 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 DHS, DHHS, DOJ and DOC.
2. Retain such books and records for a term of at least five years from the close of DHS' fiscal year in which the sub-subcontract is in effect.

D. Subcontractor's agreement to assist Contractor in the transfer of care pursuant to Section 3.17.2, Turnover Requirements, in the event of Contract termination.

E. Subcontractor's agreement to notify DHS in the event the agreement with the Contractor is amended or terminated...

F. Subcontractor's agreement that assignment or delegation of the Subcontract will be void unless prior written approval is obtained from DHS.

G. Subcontractor's agreement to hold harmless both the State and plan Members in the event the Contractor cannot or will not pay for services performed by the subcontractor pursuant to the Subcontract.

H. Subcontractor’s agreement to timely gather, preserve and provide to DHS, any records in the subcontractor’s possession, in accordance with Section 3.45, Records Related to Recovery for Tobacco Related Illnesses."  California Contract, pages 36-38.

"6.5.2.6 Delegation of QIP Activities
The Contractor is accountable for Quality Improvement even when it delegates Quality Improvement activities to its subcontractors.  The Contractor will maintain a system to ensure accountability of delegated QIP activities…"  California Contract, page 89.

"6.5.4.4 Delegated Credentialing
The Contractor will ensure the qualifications of all network practitioners, approve new providers and sites, and terminate or suspend individual providers.  The Contractor may delegate Credentialing and recredentialing activities but will monitor the completion and effectiveness of the delegated process,  If the Contractor delegates Credentialing and recredentialing activities, the Contractor will implement and maintain policies and procedures which delineate the delegated activities and responsibility for these activities."  California Contract, page 93.

"6.5.9.5 Delegating UM Activities
Contractor will ensure that delegated UM activities to subcontractors are approved and regularly evaluated.  Contractor will ensure that this process is documented."  California Contract, page 102.

"6.7.4.2 School Linked CHDP Services: Cooperative Arrangements
The Contractor will enter into one or a combination of the following arrangements with the local school district or school sites:

A. Cooperative arrangements (e.g. Subcontracts) with school districts or school sites to directly reimburse schools for the provision of some or all of the CHDP services, including guidelines for sharing of critical medical information.  The arrangements will also include guidelines specifying coordination of services, reporting requirements, quality standards, processes to ensure services are not duplicated, and processes for notification to Member/student/parent on where to receive initial and follow up services...

6.7.4.3 School Linked CHDP Services: Subcontracts
Contractor shall ensure that the Subcontracts with the local school districts or school sites meet the requirements of Article III, Section 3.28, Subcontracts, and address the following:  the population covered, beginning and end dates of the agreement, services covered, practitioners covered, outreach, information dissemination and educational responsibilities, Utilization Review requirements, referral procedures, medical information flows, patient information confidentiality, Quality Assurance interface, data reporting requirements, Grievances and complaint procedures."  California Contract, page 120.

"6.10.4 Subcontracts
The Contractor will document in the Subcontracts with Traditional and Safety-Net providers the linguistic services to be provided and the individuals who will provide the linguistic services to Members within the proposed Service Area."  California Contract, page 141.

CO

"X. SUBCONTRACTS
A. The Contractor shall be responsible for all work performed under this Contract, but may, with the approval of the Department, enter into subcontracts for the performance of work required under this Contract…

F. Proposed subcontracts shall meet the requirements of 42 CFR 434.6, as amended, prior to being submitted to the Department.  All subcontracts shall provide for access to all records by the Secretary of the U.S. Department of Health and Human Services as specified in 45 CFR 74, as amended."  Colorado Contract, pages 38-39.

CT

"3.38  Utilization Management
a.  The MCO and any subcontractor is required to be licensed by the Connecticut Department of Insurance as a utilization review company.  The MCO may subcontract with a licensed utilization review company to perform some or all of the MCO's utilization management functions...

The MCO and its subcontractors shall comply with the utilization review provisions of Public Act 97-99, Sec. 18(a)(1)."  Connecticut Contract, page 49.

FL

"14.  Subcontracts.  The plan is responsible for all work performed under this contract, but may, with the written approval of the agency, enter into subcontracts for the performance of work required under this contract...

The plan shall assure that all tasks related to the subcontract are performed in accordance with the terms of this contract. The plan shall identify in its subcontracts any aspect of service that may be further subcontracted by the subcontractor...

All model and executed subcontracts and amendments used by the plan under this contract must meet the following requirements: ...
b.  Specify the functions of the subcontractor…

d.  Specify the amount, duration and scope of services to be provided by the subcontractor, including a requirement that the subcontractor continue to provide services through the term of the capitation period for which the agency has paid the plan.

e.  Provide for timely access to physician appointments to comply with the following availability schedule: urgent care - within one day; routine sick care - within one week; well care - within one month.

f. Provide that the agency and DHHS may evaluate through inspection or other means the quality, appropriateness and timeliness of services performed.

g. Provide for inspections of any records pertinent to the contract by the agency and DHHS.

h. Require an adequate record system be maintained for recording services, charges, dates and other commonly accepted information elements for services rendered  to recipients under the contract...

j. Require safeguarding of information about recipients according to 42 CFR, Part 431, Subpart F...

o. Make full disclosure of the method and amount of compensation or other consideration to be received from the plan.  The provider shall not charge for any service provided to the member at a rate in excess of the rates established by thee plan's subcontract with the provider in accordance with Section 1128B(d)(1).  Social Security Act (enacted by Section 4704 of he 1997 Balanced Budget Act).

p. Provide for prompt submission of information needed make payment.

q.  Provide for monitoring of services rendered to recipients sponsored by the provider.

r. Provide for the participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by the plan.

s. Provide for submission of all reports and clinical information required by the plan, including EPSDT reporting (if applicable).

t. Pursuant to 42 CFR 417.479(a), make no specific payment directly or indirectly under a physician incentive plan to a physician group as an inducement to reduce or limit medically necessary services furnished to an individual enrollee...

w.  Provide for monitoring and oversight by the plan and the subcontractor to provide assurance that all licensed medical professionals are credentialed in accordance with the plan's and the agency's credentialing requirements as found in Attachment I, Section B.5., Licensure of Staff, if the plan has delegated the credentialing to a subcontractor.

x.  Contain no provision restricting the provider's ability to communicate information to the provider's patient regarding medical care or treatment options for the patient when the provider deems knowledge of such information by the patient to be in the best interest of the health of the patient.

y. Specify that if the subcontractor delegates or subcontracts any functions of the plan, that the subcontract or delegation include all the requirements of this section."  Florida Contract, pages 62-65.

FLMH

"4.18 Subcontracts...
All subcontracts executed by the contractor under the resulting contract must meet the following requirements and be approved by the agency in advance of implementation. All subcontractors must adhere to the following requirements: ...

D.  Specify the amount, duration and scope of service to be provided by the subcontractor, including a requirement that the subcontractor continue to provide services through any post-insolvency period.

E.  Provide that the agency and DHHS may evaluate through inspection or other means the quality, appropriateness, and timeliness of services performed.

F.  Specify that the subcontractor has read and agreed to the subcontract and the service provision requirements under section 2 of RFP, for services to be provided under the subcontract, and to the contractor's admission and retention criteria for the services the subcontractor will provide as indicated in the subcontractor's response to section 5.1F.3.b,(5).

G.  Provide for inspections of any records pertinent to the contract by the agency and DHHS...

J.  Require an adequate record system be maintained for recording services, charges, dates and all other commonly accepted information elements for services rendered to recipients under the contract.

K.  Require that financial, administrative and medical records be maintained for a period not less than five years from the close of the contract and retained further if the records are under review or audit until the review or audit is complete...

L.  Require safeguarding of information about recipients according to 42 CFR, Part 431, Subpart F.

M.  Require an exculpatory clause, which survives he termination of the subcontract including breach of subcontract due to insolvency, that assures that recipients or the agency may not be held liable for any debts of the subcontractor.

P.  Provide for the participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by the contractor...

T.  Contain no provision which provides incentive, monetary or otherwise, for the withholding of medically necessary care.

U.  Require adherence to the Medicaid policies expressed in applicable Medicaid provider handbooks.

V.  Require that the subcontractor secure and maintain during the life of the subcontract worker's compensation insurance for all of its employees connected with the work under this contract unless such employees are covered by the protection afforded by he provider.  Such insurance shall comply with Florida's Worker's Compensation Law; and

W.  Contain a clause indemnifying, defending and holding the Agency and the plan members harmless from costs or expense, including court costs and reasonable attorney fees to the extent proximately caused by any negligent act or other wrongful conduct arising form the subcontract agreement.  This clause must survive the termination of the subcontract, including breach due to insolvency."  Florida Mental Health RFP, pages 61-63.

GA

"1.040  Use of Subcontractors...
  Contractor may subcontract any task or portion of task to be performed under the Contract with the prior written consent of the Department."  Georgia RFP, Appendix E, page 3.

HI

"6.  Subcontracts and Assignments.  The CONTRACTOR shall not assign or subcontract any of the CONTRACTOR's duties, obligations, or interests under this Agreement and no such assignment or subcontract shall be effective unless (i) the CONTRACTOR obtains the prior written consent of the STATE and
(ii) the CONTRACTOR's assignee or subcontractor submits to the STATE a tax clearance certificate from the Director of Taxation, State of Hawaii, showing that all delinquent taxes, if any, levied or accrued under state law against the CONTRACTOR's assignee or subcontractor have been paid.  Additionally, no assignment by the CONTRACTOR of the CONTRACTOR's right to compensation under this Agreement shall be effective unless and until the assignment is approved by the Comptroller of the State of Hawaii, as provided in section 40-58, HRS."  Hawaii Contract, page 3.

HIBH

"60.600  Subcontracts/Provider Agreements
The offeror is allowed to negotiate and contract or enter into contracts or agreements with providers and other subcontractors to the benefit of the offeror as long as the providers and subcontractors meet all established criteria and provide the services in a manner consistent with the minimum standards specified.  All such agreements shall be in writing.  DHS reserves the right to inspect all subcontract and provider agreements at any time during the contract period."  Hawaii Behavioral Health RFP, pages 68-69.

"61.130  Inclusion of Audit Requirements in Subcontracts
The provisions of Subsection 61.100 and its associated subsections shall be incorporated in any subcontract/provider agreement."  Hawaii Behavioral Health RFP, pages 71-72.

IA

"4.23  Subcontracts with Providers and Other Subcontractors
All subcontracts entered into by the HMO for the performance of any obligation under this Contract shall be in writing, shall comply with the provisions of this Contract...

All restrictions, obligations and responsibilities of the HMO under this Contract shall also apply to subcontractors.  All subcontracts shall hold harmless the State, state officers and employees and Enrollees for nonpayment by the HMO to its subcontractors.  Subcontracts with Providers shall ensure that payment by the HMO to the Provider for Covered Services is payment in full and the Enrollee shall not be responsible for any additional charges or fees.  The HMO shall not enter into a subcontract with a Provider that prevents the Provider from contracting with more than one Medicaid HMO."  Iowa Contract, page 38.

IABH

"12.0 SUBCONTRACTORS
All subcontractors must meet the same standards, terms and conditions as imposed on the Contractor by this Contract...

12.1  SUBCONTRACTS FOR THE PROVISIONS OF TREATMENT SREVICES AND SUPPORTS
The Departments reserve the right to approve or disapprove any subcontracts for the provision of treatment services and supports entered into by the Contractor for the purpose of completing the provisions of this contract prior to Contractor entering into subcontracts...

If the Contractor delegates either clinical or administrative responsibilities required in this contract to a direct service provider, the Departments reserve the right to limit the direct clinical services for which that provider can be reimbursed.  The Contractor and subcontractor/provider must demonstrate both (1) an organizational structure and (2) policies and procedures which would prevent the opportunity for, or an actual practice which allows, a situation in which the Contractor and subcontractor/provider gains any financial benefit form any policy or practice related to network recruitment, referral reimbursement, service authorization, monitoring and oversight, or any other practice which might  bring financial gain...

12.2  USE OF SUBCONTRACTORS FOR OTHER THAN SERVICE PROVISION
The Contractor may enter into written subcontract(s) for performance of certain of its non-service functions arising out of this contract.  Notice of the planned use of such subcontractors shall be made by the Contractor to the Departments…..."  Iowa Behavioral Health Contract, pages 6-7.

KS

"B.  SUBCONTRACTS
The HMO has the right to subcontract for services specified under this contract...

The subcontractor(s) must be able to perform the same level of review and meet the same requirements as the HMO. The HMO must set forth a method by which to monitor the subcontractor and is ultimately responsible for the work performed.

The HMO must verify qualifications of subcontractors in accordance with all state licensing standards, all applicable accrediting standards, and any other standards or criteria established by SRS to assure quality of services...

Assure that all subcontracts shall be in writing, shall comply with the provisions of this contract, and shall include any general requirements of this contract that are appropriate to the service or activity identified…

The HMO and its subcontractors must comply with all the provisions and applicable conditions of Title VII of the Civil Rights Act of 1964, as amended; the Age Discrimination in Employment Act of 1967, as amended; Equal Pay Act of 1963; the Rehabilitation Act of 1973, as amended; The Americans with Disabilities Act of 1990 and the Civil Rights Act of 1991. If applicable, the HMO must also comply with all provisions of Executive Order #11246 including amendments, as well as rules, regulations and relevant orders of the Secretary of Labor."  Kansas Contract, pages 80-81.

KY

"IX.  SUBCONTRACTS...
B.  Requirements
  The Contractor may, with the approval of the Department, enter into Subcontracts for the performance of its administrative functions or the provision of various Covered Services to Members.  All Subcontractors must be eligible for participation in the Medicaid program as applicable. Each Subcontract, and any amendment to a Subcontract, shall be in writing, and in form and content approved by the Department in writing prior to the effective date…"  Kentucky Contract, pages 37-38.

"6.4.1.3 Nondiscrimination
  The Partnership agrees to comply with each of the following requirements, and to include in any Subcontracts the requirement that any Subcontractor, supplier, or any other person or entity who receives compensation pursuant to performance of this Application, also comply with the following requirements: ...

  Title VI of the Civil Rights Act of 1964...Section 504 of the Rehabilitation Act of 1973…The Americans with Disabilities Act of 1990…Executive Order No. 11246 of September 24, 1965, and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts.  These provide, in part, that no persons in the United States shall, on the grounds or race, color, national origin, sex, age, disability, political beliefs or religion be excluded from participation in, or denied, any aid, care, service or other benefits provided by Federal and/or State funding, or otherwise be subjected to discrimination." Kentucky RFA, page 17.

ME

"4.  Credentialing and Recredentialing...
h.  If the Contractor delegates credentialing (and recredentialing, recertification, or reappointment) activities, safeguards must be in place to address the following:
   (i)  there is a written description of the delegated activities, and the delegate's accountability;
  (ii)  the Contractor ensures that all elements/requirements outlined in this section are met;
  (iii)  the Contractor retains the right to approve new providers and sites and to terminate or suspend individual providers;
  (iv)  the Contractor has a process for monitoring the effectiveness of the delegate's credentialing and reappointment or recertification processes on a defined, regular basis."  Maine Contract, pages 32-34.

"X.  SUBCONTRACTS...
C.  SUBCONTRACT REQUIREMENTS
The Contractor shall ensure that all subcontracts state with specificity the subcontractor's functions and duties, as well as all services and benefits to be provided. The Contractor shall ensure that all subcontractors comply with all the general requirements of this Contract, and with applicable federal and state laws and regulations, including but not limited to regulations found in 42 CFR Sections 417 and 434, and in the State Medicaid Manual, Part 2 (HCFA Publication 45-2). Nothing in this Contract shall create any contractual relationship between any subcontractor and the Department.

D.  PROVIDER CONTRACTS...
All provider contracts shall incorporate expressly or by reference the applicable requirements of the Maine Medicaid Provider/Supplier Agreement. The Contractor shall ensure that providers agree not to bill an Enrollee for services covered under this Contract and provided during the Enrollee's period of HMO enrollment. All contracts with provider associations shall be signed by the individual providers or incorporate the providers' authorization for the provider association to contract on the individual provider's behalf. To the extent risk-sharing contracts are entered into by and between the Contractor and with networks or providers, Contractor shall ensure, by obtaining appropriate assurances from the Bureau of Insurance or otherwise, that such networks or providers may legally enter into such risk-sharing arrangements...

F.  INSOLVENCY PROTECTION
The Contractor shall require that, in the event it becomes insolvent, subcontractors continue to provide services until the end of the month in which the Contractor's insolvency occurs. The Contractor shall prevent subcontractors from looking to Enrollees for payment by requiring all subcontracts to contain ‘hold harmless’ and ‘continuation of benefits’ clauses that survive the termination of the subcontract due to insolvency."  Maine Contract, pages 56-57.

"D.  SUBCONTRACTORS
The Contractor shall require that each of its subcontractors, at their sole cost and expense, procure and maintain current, adequate general, professional or other insurance in the usual and customary amounts as shall be necessary to insure subcontractor and subcontractor's employees against any claim for damages arising by reason of personal injuries or death occasioned directly or indirectly in connection with the performance of subcontractor services by subcontractor, the use of any property by subcontractor, and the activities performed by subcontractor. Contractor shall require subcontractors to maintain malpractice insurance coverage in an amount equal to or greater than the minimum acceptable level established by Contractor, or such greater amount as may be mandated by law. It is the intent of the parties that no such insurance shall be deemed to waive the State's immunity from liability under the Maine Tort Claims Act, 14 M.R.S.A. §8116, by insuring the State against any risk for which the State would otherwise be immune from liability under the Maine Tort Claims Act."  Maine  Contract, page 59.

MD

"I.  THE MCO AGREES: ...
D.  To maintain, and assure that its subcontractors maintain, adequate records which fully describe the nature and extent of all goods and services provided and rendered to Enrollees, including but not limited to, medical records, charts, laboratory test results, medication records, and appointment books for a minimum of six (6) years...

Q.  To inform its subcontractors of the provisions of the Social Security Act §1128 B attached hereto and incorporated by reference."  Maryland Contract, pages 1, 4.

"10.09.65.02...
N.  An MCO and its subcontractors shall permit the following organizations to inspect, evaluate, or audit books, records, documents, files, accounts, and facilities maintained by or on behalf of the MCO or by or on behalf of any subcontractor:
(1)  The Department;
(2)  The Medicaid Fraud Control Unit of the Office of the Attorney General;
(3)  The Insurance Fraud Division of the Maryland Insurance Administration; or
(4)  Other authorized State or federal agencies."  Maryland COMAR 10.09.65.02.

"10.09.66.07...
C.  Hours of Access for Clinical Services.
(1)  An MCO shall establish, or require its subcontractors to establish, a reasonable schedule of operating hours during which its service delivery sites are open to the MCO's enrollees as follows:
  (a)  For the MCO's employee and subcontractor providers who are individual practitioners, operating hours shall be at least 20 hours per week and at least 3 days per week;
  (b)  For subcontractors who have contracted with the MCO as a group practice or facility, the operating hours shall be at least 35 hours per week…"  Maryland COMAR 10.09.66.07.

MABH

"Insurance. Unless otherwise provided by law, the Contractor shall provide, maintain and require its subcontractors to provide and maintain all insurance for its employees, including disability, worker's compensation and unemployment compensation, in accordance with the statutory requirements of any state where work is performed…"  Massachusetts MH/SAP Contract, page 5.

"B. Delegation to Subcontractors
The Contractor shall: ...
4.  include the following language in all Provider Agreements, agreements with non-Network providers and other agreements with providers:
'Providers shall not seek or accept any payment from any Recipient for any Covered Services rendered, nor shall providers have any claim against, or seek any payment from the Division. Instead, providers shall look solely to the Partnership for payment with respect to Covered Services rendered to Recipients. Furthermore, providers shall not maintain any action at law or in equity against any Recipient or the Division to collect any sums that are owed by the Partnership under this Agreement, for any reason, even in the event that the Partnership fails to pay, becomes insolvent or otherwise breaches the terms and conditions of this Agreement. This Section shall survive termination of this Agreement' (where 'Agreement' shall refer to the agreement between the Contractor and any subcontractor and where 'provider' shall refer to the subcontractor, including Network and non-Network providers, with whom the Contractor is contracting,)…"  Massachusetts MH/SAP Contract, Appendix A, pages 18-19.

MN

"Section 3.6.  Year 2000 Compliance...
Section 3.6.3.  By the HEALTH PLAN's Subcontractors.  The HEALTH PLAN shall include the requirements in 3.6.1. in all of its subcontracts for services under this Contract."  Minnesota Contract, pages 36-37.

"Section 9.1. Licensing and Certification… The HEALTH PLAN and its subcontractors shall comply with all applicable federal and state statutes and regulations, as well as local ordinances and rules now in effect and hereinafter adopted, including but not limited to Minnesota Statutes, Sections 621.695 to 62J.76 (Patient Protection Act), Minnesota Statutes, Section 62Q.47 (mental health parity), Minnesota Statutes, Section 62Q.53 (mental health medical necessity), and Minnesota Statutes, Section 62Q.19 (essential community providers).

Section 9.2. Subcontractors...

Section 9.2.4. The HEALTH PLAN shall require that all subcontractors shall provide HCFA, the Comptroller General, or their designees, and the STATE with the right to inspect, evaluate, and audit any pertinent books, documents, papers, and records of any subcontractor involving transactions related to this Contract…"  Minnesota Contract, pages 83-84.

"Section 9.2.18. The HEALTH PLAN shall include in all subcontracts for the delivery of services under this Contract a requirement that the subcontractor follow the definition of Medical Necessity in Section 2.32., and in subcontracts for the delivery of mental health services that the subcontractor additionally follow the medical necessity definition found in Minnesota Statutes, Section 62Q.53. Subcontracts shall include the definition found in Section 2.32., and the definition found in Minnesota Statutes, Section 62Q.53 where applicable."  Minnesota Contract, page 87.

"Article 15. Lobbying Disclosure. The HEALTH PLAN certifies that, to the best of its knowledge, understanding, and belief, that: ...

Section 15.3. The undersigned will require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and will require that all sub-Recipients certify and disclose accordingly…"  Minnesota Contract, pages 95-96.

MO

"2.2.1  Health Plan Administration: …Similarly, the health plan may contract with a third party (subcontractor) to perform one or more of these functions…"  Missouri RFP, page 21.

"3.5  Subcontractors:
If approved by the State of Missouri in writing, the contractor may subcontract for those services described herein provided that any subcontracts include appropriate provisions and contractual obligations to ensure the successful fulfillment of all contractual obligations agreed to by the contractor and the State of Missouri and to ensure that the State of Missouri is indemnified, saved, and held harmless from and against any and all claims of damage, loss, and cost (including attorney fees) of any kind related to a subcontract in those matters described in the contract between the State of Missouri and the Contractor."  Missouri RFP, pages 101-102.

MT

"E.  Third Party Considerations:…
2)  Collection from third-party payers is the responsibility of the CONTRACTOR or its SUBCONTRACTORS. The CONTRACTOR and SUBCONTRACTORS shall pursue collection from the third-party payer prior to any collection efforts directed toward the ENROLLEE i.e., cases in which the ENROLLEE has already received payment from the third-party payer…"  Montana Contract, page 5.

"SECTION 10  ASSIGNMENT, TRANSFER AND SUBCONTRACTING
A.  The CONTRACTOR shall have no right to and shall not assign, transfer, delegate or subcontract this contract or any right or duty arising under this contract without the written approval of the DEPARTMENT. However, the DEPARTMENT reserves the right to approve prototypes of subcontracts, in which case the CONTRACTOR need not have each use of the prototype approved. The DEPARTMENT in its discretion may grant written approval of an assignment, transfer, delegation or subcontract, provided, however, that this paragraph shall not be construed to grant the CONTRACTOR any right to such approval. Any subcontracting arrangements must comply with 42 CFR 434.6(b) and (c)."  Montana Contract, page 9.

"SECTION 17  FEDERAL REQUIREMENTS AND ASSURANCES
A.  Generally...
The CONTRACTOR shall provide for the compliance of any SUBCONTRACTORS with applicable federal requirements and assurances."  Montana Contract, page 12.

NE

"13.27 Subcontractors: The plan shall require that all subcontractors meet the same requirements as are in effect for the contractor that are appropriate to the service or activity delegated under the subcontract."  Nebraska Contract, page 86.

NEBH

"8.9 PHP Responsibility/Subcontracting: ...
Subcontractors may be used to perform duties under this contract.  If the PHP intends to utilize any subcontractor services, the subcontractor’s level of effort, tasks and time allocation shall be clearly defined in the PHP’s contractual relationship with the subcontractor…"  Nebraska Behavioral Health Contract, page 18.

"11.30  Subcontractors: The PHP shall require all subcontractors to meet the same requirements as are in effect for the PHP that are appropriate to the service or activity delegated under the subcontract."  Nebraska Behavioral Health Contract, page 59.

NV

"18.  All subcontracts to implement this contract must be in writing and must meet all federal requirements for a Medicaid contract to include, but not be limited to, 42 CFR §436.6.  In the event any subcontract is determined not to meet federal requirements and results in a federal disallowance of federal funds, the Contractor will be financially responsible to refund the amount of the federal disallowance and the corresponding state share to DHCFP.  The state share will be considered liquidated damages.  If such disallowance is treated as a default or breach under paragraph 7, any such liquidated damages are  not exclusive and are in addition to any other remedies available under this contract.  All existing subcontracts requiring amendments to meet the requirements of this contract, shall be amended.  All future subcontracts must meet the requirements of this contract and any amendments thereto."  Nevada Contract, page 9.

NH

"Article II
Functions and Duties of Contractor...

2.7.2  Without limiting the generality of any other provision of this Agreement, if this Agreement is funded in any part by monies of the United States, Contractor shall: ...
(d) Cause all of the foregoing provisions of Section 2.7 to be inserted in all Subcontracts for any work covered by this Agreement so that the provisions will be binding on each Subcontractor; provided however. that the foregoing provisions shall not apply to Subcontract for standard commercial supplies or raw materials. Contractor shall take such action with respect to any Subcontract as the State, or, where applicable, the United States, may direct as a means of enforcing such provisions, including sanctions for noncompliance.

2.17  SUBCONTRACTS...Contractor subcontracts for the services outlined in Exhibit A.3. For example. physicians may or may not be employees of the Contractor. The Contractor subcontracts for the provision of medical services. The Contractor further agrees that it will not subcontract for any Non-Covered Services. All Subcontracts must include all applicable requirements contained in 42 CFR 434.6..." New Hampshire General Service Agreement, pages 8-10.

"Article VII
Quality Improvement Program

7.1  The Contractor shall ensure the delivery of quality care with the primary goal of improving the health status of Enrollees. The Contractor shall maintain an active commitment to Continuous Quality Improvement/Quality Management in all aspects of its service delivery...

(G) Delegation of QIP activities.
(1) The Contractor will be accountable for all QIP functions including those delegated to other entities.
(2) There must be a written description of any delegated QA activities, the delegate's accountability for the activities and the frequency of reporting to the Contractor.
(3) The Contractor must have written procedures for monitoring the implementation of the delegated functions.
(4) There must be evidence of continuous evaluation of delegated activities by the Contractor. which includes regular specified reports

(H)  Provider Credentialing/Re-Credentialing...
(5) If the Contractor delegates credentialing and/or recredentialing activities, there must be a written description of the delegated activities and the delegate's accountability for these activities.
  (a)  The Contractor must monitor the effectiveness of the delegate's credentialing and recredentialing process.
  (b)  The Contractor retains the right to approve new providers and sites, and to terminate or suspend individual providers.
  (c)  The. Contractor must have written policies and procedures for the suspension, reduction or termination of practitioner privileges.
  (d)  There must be a provider appellate process for instances where the Contractor chooses to reduce, suspend or terminate a practitioner's privileges with the Contractor."  New Hampshire General Service Agreement, pages 29, 31.

NJ

"ARTICLE 17
RECORDS MAINTENANCE AND AUDIT RIGHTS...
17.3  The contractor hereby agrees to maintain an appropriate recordkeeping system for services to enrollees…All subcontractors shall comply with, and all subcontracts shall contain the requirements stated in this paragraph…"  New Jersey Contract, pages 92-93.

"ARTICLE 21
CONTRACTS AND SUBCONTRACTS...
21.4  All subcontracts must be in writing and must fulfill the requirements of 42 CFR part 434 that are appropriate to the service or activity delegated under the subcontract.
  A.  Subcontracts must contain provisions allowing DMAHS and HHS  to evaluate through inspection or other means, the quality, appropriateness and timeliness of services performed under a subcontract to provide medical services (42 CFR 434.6(a)(5)).
  B.  Subcontracts must contain provisions pertaining to the maintenance of an appropriate record system for services to enrollees. (42 CFR 434.6(a)(7))
  C.  Each subcontract must contain sufficient provisions to safeguard all rights of enrollees and to insure that the subcontract complies with all applicable state and federal laws, including confidentiality…

21.14  All subcontractors must comply with record retention requirements of 42 CFR part 74.

21.15  All subcontractors must, at a minimum, meet Medicaid provider requirements and standards as well as all other federal and state requirements…"  New Jersey Contract, pages 118-122.

NM

"2.H.3  Financial Reporting...
2.H.3.b  The CONTRACTOR and its subcontractors shall maintain a system of accounting in accordance with generally accepted accounting principles.  The accounting system shall clearly
document all financial transactions between the CONTRACTOR and its subcontractors, and the CONTRACTOR and HSD. These transactions shall include but are not limited to claim payments. refunds, and adjustments of payments."  New Mexico Contract, pages 62-63.

"20.4  Subcontracting Requirements...
 The CONTRACTOR is required to give HSD prior notice with regard to its intent to subcontract certain significant contract requirements as specified herein or in writing by HSD including, but not limited to: credentialing, utilization review, and claims processing...

20.4.c  Minimum Requirements
Subcontracts must contain at least the following provisions:
  20.4.c.I  Subcontracts must be executed in accordance with all applicable Federal and State laws. regulations, policies and rules:
  20.4.c.ii  Subcontracts must identify the parties of the subcontract and their legal basis of operation in the State of New Mexico:
  20.4.c.iii  Subcontracts must include the procedures and specific criteria for terminating the subcontract:
  20.4.c.iv  Subcontracts must identify the services to be performed by the subcontractor and those services performed under any other subcontracts). Subcontracts must include provision(s)
describing how services provided under the terms of the subcontract are accessed by members:
  20.4.c.v  Subcontracts must include the reimbursement rates and risk assumption. if applicable:
  20.4.c.vii  1)subcontracts must require that member information be kept confidential. as defined by Federal and State law;
  20.4.c.viii  Subcontracts must include a provision that authorized representatives of HSD have reasonable access to facilities and records for financial and medical audit purposes;
  20.4.c.x  The subcontractor must accept payment from the MCO as payment for any services included in the benefit package, and cannot request payment from HSD or from Medicaid
members (except for copayments explicitly permitted) for services performed under the subcontract:
  20.4.c.xi.  If the subcontract includes primary care, provisions for compliance with PCP requirements delineated in the primary MCO contract apply;
  20.4.c.xiii.  Subcontracts shall include provision for termination for any violation of applicable HSD. State or Federal requirements;
  20.4.c.xiv  The subcontract may not prohibit a provider or other subcontractor (with the exception of third party administrators) from entering into a contractual relationship with another MCO.
  20.4.c.xv  The subcontract may not include any incentive or disincentive that encourages a provider or other subcontractor not to enter into a contractual relationship with another MCO;
  20.4.c.xvi  The subcontract cannot contain any gag order provisions."  New Mexico Contract, page 93.

NY

"22.  SUBCONTRACTS AND PROVIDER AGREMENTS…
22.5 Required Components
a) The Contractor shall impose obligations and duties on its subcontractors, including its Participating Providers, that are consistent with this Agreement, and that do not impair any rights accorded to LDSS, SDOH, or DHHS…"  New York Contract, page 22-1.

NC

"12.1  Requirements...
All subcontracts must clearly identify the functions that are subcontracted and provide the Division upon request with results from any audits of reviews of subcontractors.  All subcontracts shall:
a.  Identify the population...
b.  Specify the amount, duration, and scope of services...
c.  Specify procedures and criteria for extension, re-negotiation and termination;
d.  Make full disclosure of the method and amount of compensation...
e.  Provide for monitoring by the Plan of the quality of services...
f.  Contain no provision which provides incentives, monetary or otherwise, for the withholding from Members of medically necessary services;
g.  Contain a prohibition on assignment or any further subcontracting without the prior written consent...
h.  Incorporate all provisions of this Contract to the fullest extent applicable to the service or activity delegated pursuant to the subcontract, including without limitation, the obligation to comply with all applicable federal and State laws and regulations, all rules, policies and procedures of the Department, and all standards governing the provision of Covered Services and information to all Members; all quality assurance requirements; all record keeping and reporting requirements; the obligation to maintain the confidentiality of information; all rights of the Division and other officials to inspect, monitor and audit operations; all indemnification and insurance."  North Carolina Contract, pages 21-22.

ND

"9  ASSIGNMENT, TRANSFER, AND SUBCONTRACTING
A.  The Contractor shall have no right to... subcontract this con-tract or any right or duty arising under this contract without the written approval of the Department...

B.  In the event the Department approves of any...  subcontract...  subcontract must meet any conditions stated in the Department's written approval.  The... subcontract must be in writing and must contain all provisions required by this contract or applicable laws and regulations…"  North Dakota Contract, page 7.

"15  FEDERAL REQUIREMENTS AND ASSURANCES...
E.  The Contractor shall provide for the compliance of any subcontractors with applicable federal requirements and assurances."  North Dakota Contract, pages 11-12.

OH

"7.  Provider Networks…
(d)  Subcontracts…
All MCPs will be required to use the Model Medicaid Subcontract Addendum in subcontracting with their health care providers.  As specified by ODHS, the fully executed subcontract addendum must be submitted to ODHS for prior-approval of a provider."  Ohio RFP, page 30.

"APPENDIX J…
MODEL MEDICAID ADDENDUM…

ADDENDUM PROVISIONS...
Participating providers providing health care services to (MCP Name's) members enrolled pursuant to a Medicaid contract agree to abide by all of the following specific terms:

1.  Provider shall not discriminate in the delivery of services based on the enrollee's race, color, religion...

2.  Provider shall be bound by the same standards of  confidentiality which apply to ODHS and the state of Ohio as described in OAC rule 5101:1-1-03.

3.  Provider agrees to comply with the provisions for recordkeeping and auditing...

4.  Provider agrees to allow the MCP access to all member medical  records for a period of not less than six years...

6.  Provider agrees not to charge the member or ODHS any copayments for covered services...

8.  Provider is duly licensed or certified under applicable state and federal statutes and regulations to provide the health care services that are the subject of the Agreement.

9.  If the provider is currently a Medicaid provider, provider must meet the qualifications specified in OAC rule 5101:3-26-05 (E).

11.  Provider agrees to comply with the MCP's quality improvement program.

12.  Provider agrees to comply with the ODHS annual Quality Improvement review as described in OAC rule 5101:3-26-07.

13.  All laboratory testing sites providing services to members must have either a ‘Clinical Laboratory Improvement Amendments (CLIA)’ certificate of waiver...

14.  Any home health agency used for members must be Medicare certified...

20.  Unless an exception to this section is approved in writing by ODHS, if provider is a PCP (primary care provider), each provider, individually or as part of a group, agrees to serve  a minimum of 50 of the MCP's Medicaid members at each practice site and the maximum number of MCP' s Medicaid members at each practice site as stated above the signature line on the signature page of this Medicaid Addendum…"  Ohio RFP, Appendix J, pages 1-3.

"5101:3-26-05  Managed care plan:  provider panel and subcontracting requirements.
(A)  Obligations...
(2)... All subcontracts must be in writing and in accordance with paragraph (D) of this rule and 42 CFR 434.6...
(5)  MCPs must have current, fully executed subcontracts for health care services in effect for those subcontractors as specified by ODHS...

(D)   Subcontracts.
FOR THE PURPOSES OF THIS PARAGRAPH, THE TERM SUBCONTRACT MEANS THE MCP'S MEDICAID ADDENDUM.  The content of MCP subcontracts must be approved in writing by ODHS prior to use.  All subcontracts must be in writing and contain at least the following elements:
(1)  An agreement by the subcontractor to comply with the provisions for record keeping and auditing in accordance with Chapter 5101:3-26 of the Administrative Code;
(2)  Specification of the population and county to be served;
(3)  Specification of the services to be provided;
(4)  Specification that the subcontract CONTAIN THE SAME TERMS THAT ARE APPLICABLE TO THE CONTRACTED SERVICE, be governed by, and construed in accordance with, all laws, regulations, and contractual obligations of the MCP...
(7)  Specification of the procedures to be employed upon termination of the subcontract, including the agreement to promptly supply all records necessary for the settlement of outstanding medical claims;
(8)  Full disclosure of the method and amount of compensation or other consideration to be received by the subcontractor from the MCP;
(9)  An agreement not to discriminate in the delivery of services based on the enrollee's race, color, religion, sex, sexual orientation, age, disability, national origin, veteran's status, ancestry, health status or need for health services;
(10)  An agreement by the subcontractor to hold harmless both ODHS and enrollees in the event that the MCP cannot or will not pay for covered services performed by the subcontractor pursuant to the subcontract;
(11)  An agreement not to charge the enrollee or ODHS any copayments for covered services;
(12)  A specification that the provider is duly licensed or certified under applicable state and federal statutes and regulations to provide the health care services that are the subject of the subcontract;
(13)  An agreement that subcontractors who are currently medicaid providers meet the qualifications specified in paragraph (E) of this rule...
(17)  The subcontractor's agreement to make available for transfer to new providers the medical records of enrollees at no cost to the enrollee...
(19)  A requirement securing cooperation with the MCP's quality program (QP) in all its provider subcontracts and employment agreements for physician and nonphysician providers;
(20)  A specification that hospitals and other subcontractors must allow the MCP access to all enrollee medical records for a period of not less than six years from the date of service and allow access to all record-keeping, audits, and medical records to ODHS and the MFCU;
(21)  A specification, appearing above the signature(s), on the signature page in all PCP subcontracts stating the maximum number of MCP enrollees which each PCP can serve at each practice site for that MCP;
(22)  A specification that the subcontractor must cooperate with the ODHS annual review identified in rule 5101:3-26-07 of the Administrative Code;
(23)  A specification that the subcontractor must be bound by the same standards of confidentiality which apply to ODHS and the state of Ohio as described in rule 5101:1-1-03 of the Administrative Code...
(28)  A specification that the MCP must not prevent MCP providers from discussing all medically-necessary treatment options with enrollees;
(29)  A specification that the subcontractor must provide the services of sign language or bilingual language assistance in the primary language of a hearing impaired or LEP enrollee..."  Ohio RFP, Appendix E, OAC 5101:3-26-05, pages 1-6.

OK

"3.5.5  Subcontracts and Delegation of Duty
Health Plan may enter into written subcontract(s) for performance of certain of their contract responsibilities listed in Chapter 2 of this contract. All subcontracts must be in writing, and fulfill the requirements of 42 CFR §434.6, that are appropriate to the service or activity delegated under the contract...

All of the program standards described in Chapter Two of the RFP shall apply to subcontractors, to the extent they are relevant to the duties they are performing…"  Oklahoma RFP, pages 81-82.

ORMH

"O.  Delegation of Activities...
Subject to the provisions of this section, Contractor may subcontract any or all of the work to be performed under this Agreement...

2.  Contractor shall have a written Agreement that specifies the delegated activities and reporting responsibilities of the subcontractor. Contractor shall notify the Division in writing of subcontractor and activities to be delegated.

3.  The following requirements of the MHO Agreement may not be delegated:
  a.  Oversight and Monitoring of QA/QI Activities;
  b.  Adjudication of Final Appeals in a Member Complaint and Grievance Process; and
  c. Service Delivery Needs Assessment

4.  Contractor's agreement with the subcontractor shall provide for the revocation of the delegation or imposition of other sanctions if the performance of the subcontractor is inadequate to meet the requirements of the MHO Agreement...

6.  Contractor shall notify Division in writing of work in this agreement to be subcontracted. Contractor shall ensure that all subcontracts meet requirements described below and shall incorporate portions of this Agreement, as applicable, based on the scope of work to be subcontracted.
a.  Be in writing and incorporate each applicable requirement of this Agreement...

b.  Clearly identify the work to be performed by the subcontractor and what of that work, if any, the subcontractor may further subcontract.

c.  Ensure that the requirements of 42 CFR part 434 that are appropriate to the services or activity required under the subcontract are fulfilled.

d.  Contain a provision that the subcontractor shall not bill, charge, seek compensation, remuneration or reimbursement from, or have recourse against Division or any OMAP Member for Covered Services provided during the period for which Capitation payments were made by the Division through OMAP to Contractor with respect to said OMAP Member, even if Contractor becomes insolvent.

e.  Contain a provision that the subcontractor shall continue to provide Covered Services during periods of Contractor Insolvency or cessation of operations through the period for which Capitations payment were made to the contractor.

f.  Contain a  provision requiring the subcontractor to follow OAR 410-141--0420-, Billing and Payment Under the Oregon Health Plan, when submitting Fee-For-Service claims for Oregon Health Plan services provided to OMAP members that are not Covered Services.

g.  In cases where the subcontractor has assumed any Risk covered under this Agreement, contain a provision that the subcontractor has to protect itself against loss by either self-insuring or providing proof of Reinsurance and by maintaining a Restricted Reserve Fund as described in Exhibit C, Solvency Plan and Financial Reporting.

h.  If Contractor chooses to delegate the Complaints and Grievance process, Contractor shall require the subcontractor to have a written policies and procedures for accepting, processing and responding to all Complaints and Grievances...

i.  Contain a provision that data used for analysis of delivery system Capacity, Consumer satisfaction, and financial solvency, and Encounter, client process monitoring, and Acute Inpatient Psychiatric Care admission data submission must be provided to Contractor within time frames sufficient to allow Contractor to meet reporting requirements described in Exhibit A...

j. Contain a provision that requires the subcontractor to have a planned, systematic and ongoing process for monitoring, evaluating and improving the quality and Appropriateness of Covered Services provided to OMAP Members.

k.  Contain a provision that requires the subcontractor to participate in QA and QI activities of Contractor, or those of the Division if requested to do so.

l.  Contain a provision that requires the subcontractor to provide access to records and facilities as described in OAR 410-141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping...

m.  Contain a provision that requires the subcontractor to cooperate withal  processes and procedures of abuse reporting, investigations, and protective services…"  Oregon Mental Health Contract, pages 37-39.

PA

"N.  GRIEVANCE AND APPEALS...
2.  Member Complaint and Grievance System...
The HMO must ensure that subcontractors, who have the authority to approve or disapprove service requests, comply with the complaint and grievance procedures and reporting requirements established by the HMO and approved by the Department…"  Pennsylvania RFP, pages 80-81.

"R. CONTRACTS AND SUBCONTRACTS...
 All subcontractors to perform part or all of the HMO's responsibilities shall include the same level of services and procedural protections set forth in the contract with the HMO, the RFP, and the successful proposal...

All contracts and subcontracts must be in writing and must: ...
•  Meet the applicable requirements of 42 CFR Subsection 434.6;
•  Include nondiscrimination provisions;
•  Include the provisions of the Americans with Disabilities Act...
•  Contain a provision in all subcontracts...that the subcontractor will report all new third party resources to the HMO identified through the provision of medical services...

S. RECORDS RETENTION
1. General
The HMO and its subcontractor(s) must agree to maintain books and records relating to the HealthChoices Program services and expenditures, including reports to the Department and source information used in preparation of these reports…

The HMO and its subcontractor(s) shall, at its own expense, make all records available for audit, review or evaluation by the Commonwealth, its designated representatives or federal agencies...

The HMO and its subcontractor(s) shall maintain books, records, documents, and other evidence pertaining to all revenues, expenditures and other financial activity pursuant to this contract as well as to all required programmatic activity and data pursuant to this contract…"  Pennsylvania RFP, pages 100-102.

PABH

"g.  Records Retention
  1)  General
  The MCO and its subcontractor(s) must agree to maintain books and records relating to the HealthChoices program services and expenditures, including reports to the Department and source information used in preparation of these reports...

  The MCO and its subcontractor(s) also must agree to comply with all standards for record keeping specified by the Commonwealth...

  The MCO and its subcontractor(s) also must agree to comply with all standards for record keeping specified by the Commonwealth...

  The MCO and its subcontractor(s) must, at its own expense, make all records available for audit, review or evaluation by the Commonwealth, its designated representatives, or federal agencies...

  The MCO and its subcontractor(s) shall maintain books, records, documents, and other evidence pertaining to all revenues…"  Pennsylvania Behavioral Health RFP, page 60.

RI

"3.05.05  Subcontracts And Delegation of Duty
Contractor may enter into written subcontract(s) for performance of certain of its contract responsibilities listed in Article II of this Agreement.  All subcontracts must be in writing and fulfill the requirements of 42CFR 434.6 that are appropriate to the service or activity delegated under this Agreement.  Contractor shall make available all subcontracts for inspection by the State upon request for the State's prior approval...

All of the program standards described in Article II shall apply to sub-contractors, to the extent relevant, to the duties they are performing…"  Rhode Island RFP, page 61.

SC

"3.2.7  If the Contractor has delegated the credentialing to a subcontractor, there shall be a written description of the delegation of credentialing activities within the subcontract. The subcontract must require the subcontractor to provide assurance that all licensed medical professionals are credentialed in accordance with the Contractor's and SCDHHS's credentialing requirements."  South Carolina Contract, page 13.

"5.1  Subcontract Requirements
All subcontracts executed by the Contractor pursuant to this section shall, at a minimum, include the requirements listed below...
5.1.5  Specify that the services covered by the subcontractor agreement must be in accordance with the Title XIX SC State Medicaid Plan and require that the subcontractor shall provide these services to members through the last day that the subcontract is in effect, all final Medicaid benefit determination are within the sole and exclusive authority of SCDHHS or its designee;
5.1.6  Specify that the subcontractor may not refuse to provide medically necessary or covered preventive services to Medicaid HMO Program members covered under this Contract for non-medical reasons;
5.1.7  Require that the subcontractor be currently licensed and/or certified under applicable state and federal statutes and regulations ...
5.1.9  Provide that emergency services be rendered without the requirement of prior authorization of any kind;
5.1.10 If the subcontractor performs laboratory services, the subcontractor must meet all applicable state and federal requirements;
5.1.11  Require that an adequate record system be maintained for recording services, service providers, charges, dates and all other commonly accepted information elements for services rendered to members pursuant to the agreement...
5.1.12 Require that any and all records be maintained for a period not less than five (5) years from the expiration date of the subcontract...
5.1.13 Provide that SCDHHS, U.S. Department of Health and Human Services (HHS)...shall have the right to evaluate through inspection, or other means, whether announced or unannounced, any records pertinent to this Contract including quality, appropriateness and timeliness of services and such evaluation, and when performed, shall be performed with the cooperation of the Contractor...
5.1.14 Whether announced or unannounced, provide for the participation and cooperation in any internal and external quality assurance review, utilization review, peer review and grievance procedures established by the Contractor and/or SCDHHS or its designee;
5.1.15 Specify that the subcontractor shall monitor the quality of services delivered under the agreement and initiate corrective action where necessary to improve quality of care...
5.1.16 Require that the subcontractor comply with corrective action plans initiated by the Contractor and/or required by SCDHHS;
5.1.17 Provide for submission of all reports and clinical information required by the Contractor, including EPSDT (if applicable);
5.1.18 Require safeguarding of information about Medicaid HMO Program members according to applicable state and federal laws...
5.1.20 Make full disclosure of the method and amount of compensation or other consideration to be received from the Contractor;
5.1.21 Provide for prompt submission of information needed to make payment…"  South Carolina Contract, pages 29-31.

TN

"2-10.    Administration and Management...
  If the subcontract is for the purpose of providing or securing the provision of  enrollee benefits, the subcontract must specify that the subcontractor must adhere to the Quality of Care Monitors included in the Agreement as Attachment IV. The Quality of Care Monitors shall be included as part of the subcontract between the CONTRACTOR and the subcontractor or provided separately at the time the subcontract is executed, provided however, if the Quality of Care Monitors is not included in the subcontract, it shall be referenced in the agreement as being provided separately upon execution of the subcontract…"  Tennessee Contract, page 46.

TX

"3.2  NON-PROVIDER SUBCONTRACTS
3.2.1  HMO must enter into written contracts with all subcontractors and maintain copies of the subcontracts in HMO’s administrative office...

3.2.4  HMO and all intermediary entities must include the following standard language in each subcontract and ensure that this language is included in all subcontracts down to the actual provider of the services...
3.2.4.1  [Contractor] is subject to all state and federal laws, rules and regulations that apply to persons or entities receiving state and federal funds...
3.2.4.2  [Contractor] understands and agrees that HMO has the sole responsibility for payment of services rendered by the [Contractor] under this contract...
3.2.4.3  [Contractor] understands and agrees that TDH is not liable or responsible for payment for any services provided under this contract.
3.2.4.4  [Contractor] agrees that any modification, addition, or deletion of the provisions of this agreement will become effective no earlier than 30 days after HMO notifies TDH of the change.
3.2.4.5  This contract is subject to state and federal fraud and abuse statutes.  [Contractor] will be required to cooperate in the investigation and prosecution of any suspected fraud or abuse...

3.2.5  The Texas Medicaid Fraud Control Unit must be allowed to conduct private interviews of HMO personnel, subcontractors and their personnel, witnesses, and patients…"  Texas Contract, pages 14-16.

"5.4  SAFEGUARDING INFORMATION...
5.4.4  HMO must require that subcontractors have mechanisms in place to ensure Member’s (including minor’s) confidentiality for family planning services.

5.5  NON-DISCRIMINATION
HMO agrees to comply with and to include in all subcontracts a provision that the subcontractor will comply with each of the following requirements:
5.5.1  Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990...
5.5.2  Texas Health and Safety Code Section 85.113 (relating to workplace and confidentiality guidelines regarding AIDS and HIV).
5.5.3   The provisions of Executive Order 11246, as amended by 11375, relating to Equal Employment Opportunity.
5.5.4  HMO shall not discriminate with respect to participation, reimbursement, or indemnification as to any provider who is acting within the scope of the provider's license or certification under applicable State law, solely on the basis of such license or certification."  Texas Contract, pages 29-30.

"6.7  FAMILY PLANNING - SPECIFIC REQUIREMENTS…
6.7.5  HMO must require, through contractual provisions, that subcontractors have mechanisms in place to ensure Member’s (including minor’s) confidentiality for family planning services."  Texas Contract, pages 40-41.

"6.15.8  The subcontract with the respective TDH regional offices and city and county health departments, as described in Article 7.16.1, must include, but not be limited to, the following topics:
6.15.8.1  Access for Case Investigation.  Procedures must be established to make Member records available to public health agencies with authority to conduct disease investigation, receive confidential Member information, and follow up.

6.15.8.2  Medical Records and Confidentiality.  HMO must require that providers have procedures in place to protect the confidentiality of Members provided STD/HIV services...HMO must inform and require its providers who provide STD/HIV services to comply with all state laws relating to communicable disease reporting requirements…"  Texas Contract, page 52.

"7.2  PROVIDER CONTRACTS…
7.2.8  HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract.  This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts:

7.2.8.1  [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program.  HMO must provide copies of the TDH/HMO Contract to the [Provider] upon request.  [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds...

7.2.8.2  [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract...

7.2.8.3  [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract.  Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill a Medicaid recipient for a covered service...

7.2.8.5... [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse...

7.2.8.6  [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH.

7.2.8.7  HMO is prohibited from imposing restrictions upon the [Provider’s] free communication with Members about a Member’s medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom [Provider] contracts.

7.2.8.8  The Texas Medicaid Fraud Control Unit must be allowed to conduct private interviews of [Providers] and the [Providers’] employees, contractors, and patients…"  Texas Contract, pages 54, 56-57.

"7.18  DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs)...
7.18.2  In addition to the mandatory provisions for all subcontracts under Articles 3.2. and 7.2, all HMO/delegated network contracts must include the following mandatory standard provisions:
7.18.2.1  HMO is required to include subcontract provisions in its delegated network contracts which require the UM protocol used by a delegated network to produce substantially similar outcomes, as approved by TDH, as the UM protocol employed by the contracting HMO...
7.18.2.2  Delegated networks that are delegated claims payment responsibilities by HMO must also have the responsibility to submit encounter, utilization, quality, and financial data to HMO.  HMO remains responsible for integrating all delegated network data reports into HMO’s reports required under this contract...
7.18.2.3  The delegated network must comply with the same records retention and production requirements, including Open Records requirements, as the HMO under this contract.
7.18.2.4  The delegated network is subject to the same marketing restrictions and requirements as the HMO under this contract.
7.18.2.5  HMO is responsible for ensuring that delegated network contracts comply with the  requirements and provisions of the TDH/HMO contract...

7.18.3  HMO cannot enter into contracts with delegated networks to provide services under this contract which require the delegated network to enter into exclusive contracts with HMO as a condition for participation with HMO...

7.18.4  All delegated networks that limit Member access to those providers contracted with the delegated network (closed or limited panel networks) with whom HMO contracts must either independently meet the access provisions of 28 Texas Administrative Code §11.1607, relating to access requirements for those Members enrolled or assigned to the delegated network, or HMO must provide for access through other network providers outside the closed panel delegated network.

7.18.5  HMO cannot delegate to a delegated network the enrollment, re-enrollment, assignment or reassignment of a Member…"  Texas Contract, pages 77-78.

UT

"D.  Subcontracts...
  2.  Any Covered Service may be Subcontracted...
  Any Covered Service may be subcontracted.  All subcontracts will be in writing and will include the general requirements of this Contract that are appropriate to the service or activity including
confidentiality requirements and will assure that all duties o the CONTRACTOR under this Contract are performed...

  5.  Compliance with CONTRACTOR's Quality Assurance Plan...
  All subcontracts with the CONTRACTOR must include a requirement securing cooperation with the CONTRACTOR'S Quality Assurance Plan and activities and must allow the CONTRACTOR access to the subcontractor's medical records of its Enrollees."  Utah Contract, Attachment B, pages 12-13.

UTMH

"C.  Subcontracts
  1.  Any Covered Service may be subcontracted.
  2.  The CONTRACTOR will assure that all subcontracts are in writing and will include any general requirements of this Contract that are appropriate to the service or activity and will assure that all duties of the CONTRACTOR under this Contract are performed...
  3.  All subcontracts will include the provision that if the subcontractor becomes insolvent or bankrupt, Enrollees will not be liable for the debt of the subcontractor...
  7.  All subcontracts with the CONTRACTOR must include a requirement securing cooperation with the CONTRACTOR's quality improvement plan and activities and must allow the CONTRACTOR access to subcontractor's medical records of its Enrollees."  Utah Mental Health Contract, pages 12-13.

VA

"B.  CONTRACTOR MANAGEMENT AND ADMINISTRATION
The Contractor may enter into subcontracts for the provision or administration of any or all Medallion II and CMSIP covered services or enhanced services...

All subcontracts entered into pursuant to this Contract shall be in writing and fulfill the requirements of this Contract and applicable Federal and State laws and regulations..

Subcontracts with the Contractor for administrative services in the areas of planning, finance, reporting systems, administration, quality assessment, credentialing/recredentialing, utilization management, enrollee services, claims processing, or provider services must be submitted to the Department at least thirty (30) calendar days prior to their effective date.  All subcontracts are subject to the Department's written approval… Subcontracts which require the subcontractor to be responsible for the provision of Medallion II covered services must include the terms set forth in Attachment V..."  Virginia Contract, page 17.

"L.  QUALITY IMPROVEMENT (QI)...
5.  Utilization Management Program Description...
If the Contractor delegates (subcontracts) responsibilities for UM with a subcontractor, the Contract must have a mechanism in place to ensure that these standards are met by the subcontractor…"  Virginia Contract, pages 73-75.

WA

"7.2  Required Provisions:  Subcontracts must be in writing, consistent with the provisions of 42 CFR 434.6.
a.  All subcontracts must contain the following provisions:
1.  Identification of the parties of the subcontract and their legal basis for operation in the state of Washington.
2.  Procedures and specific criteria for terminating the subcontract
3.  Identification of the services to be performed by the subcontractor and which of those services may be subcontracted by the subcontractor.
4.  Reimbursement rates and procedures for services provided under the subcontract.
5.  Release to the Contractor of any information necessary to perform any of its obligations under this agreement.
6.  Reasonable access to facilities and financial and medical records for duly authorized representatives of DSHS or DHHS for audit purposes, and immediate access for Medicaid fraud investigators.
7.  No assignment of the subcontract shall take effect without the DSHS's written agreement.

b.  Health care provider subcontracts, including those for facilities, must also contain the following provisions:
1.  A quality improvement system tailored to the nature and type of services subcontracted, which affords quality control for the health care provided, including but not limited to the accessibility of medically necessary health care, and which provides for a free exchange of information with the Contractor to assist the Contractor in complying with section 5.1.
2.  Records necessary to adequately document services provided to members shall be kept by the subcontractor.
3.  Information about members, including their medical records, shall be kept confidential in a manner consistent with state and federal laws and regulations.
4.  The subcontractor agrees to hold harmless DSHS and its employees, and all members served under the terms of this agreement in the event of non-payment by the Contractor.  The subcontractor further agrees to indemnify and hold harmless DSHS and its employees against all injuries, deaths, losses, damages, claims, suits, liabilities, judgments, costs and expenses which may in any manner accrue against DSHS or its employees through the intentional misconduct, negligence, or omission of the subcontractor, its agents, officers, employees or contractors.
6.  If the subcontract includes physician services, provisions for compliance with the PCP requirements stated in this agreement.
7.  A ninety (90) day termination notice provision.
8.  A specific termination provision for termination with short notice when a provider is excluded from participation in the Medicaid program.

c.  As new health care provider subcontracts are signed, and existing health care provider subcontracts are renewed, renegotiated, or updated, those subcontracts that delegate administrative functions under the terms of this agreement must include the following additional provisions:
1.  That the subcontractor must maintain the Contractor's solvency requirements for liquidity and/or capital reserves throughout the contract period.
2.  That the terms and conditions of this agreement, between DSHS and the Contractor, apply to the subcontractor for any contract responsibility the Contractor has delegated in the subcontract.
3.  Clear descriptions of any administrative functions not delegated by the Contractor in the subcontract, including but not limited to utilization/medical management, claims processing, member complaints and appeals, and the provision of data or information necessary to fulfill any of the Contractor's obligations under this agreement.
4.  How frequently and by what means the Contractor will monitor compliance with solvency requirements and requirements related to any administrative function delegated in the subcontract.
5.  Whether referrals for members will be restricted to providers affiliated with the group and, if so, a description of those restrictions."  Washington Contract, pages 30-32.

"C.  HEALTH SERVICES CONTRACTING  [QI 3]
Individual practitioner and organizational provider contracts must specify cooperation with the QI program.
1.  The contractor must incorporate language into its contracts with practitioners that specifically require that:  [QI 3.1]
  a)  The practitioners cooperate with QI activities;  [QI 3.1.1]
  b)  The contractor has access to the practitioners medical records to the extent permitted by state law;  [QI 3.1.2]
  c)  The contractor allows open practitioner-patient communication regarding appropriate treatment alternatives and without penalizing practitioners for discussing medically necessary or appropriate care for the patient. [QI 3.1.3]  (C) RCW 48.43.075

2.  The contractor must incorporate language into its contracts with providers that specifically require:  [QI 3.2]
  a)  The providers cooperate with QI activities; and  [QI 3.2.1]
  b)  The contractor has access to the providers' medical records to the extent permitted by state law.  [QI 3.2.2]"  Washington Contract, QIP-2000 Standards, pages 3-4.

"K.  DELEGATION OF QI ACTIVITY [QI 13]
If the contractor delegates any QI activities, there must be evidence of oversight of the delegated activity.  (A)
1.  A mutually agreed upon document must describe:
  a)  the responsibilities of the contractor and delegated agency;
  b)  the delegated activities;
  c)  the frequency of reporting to the contractor;
  d)  the process by which the contractor evaluates delegated agency's performance;
  e)  remedies available to the contractor if obligations are not fulfilled by delegated agency.

2.  The contractor must maintain evidence that the contractor:
  a)  evaluates the delegated agency's capacity to perform delegated activities prior to delegation;
  b)  approves the delegated agency's QI workplan and program description annually;
  c)  evaluates annually whether the delegated agency's activities are being conducted according to the contractor's expectations and these standards."  Washington Contract, QIP-2000 Standards, page 10.

"K.  DELEGATION OF UM  [UM 12]
If the contractor delegates any UM activities, the contractor must maintain evidence of oversight of the delegated activity.
1.  The contractor must maintain a mutually agreed upon document describing:  [UM 12.1]
  a)  responsibilities of the contractor and delegated agency;  [UM 12.1.1]
  b)  delegated activities;  [UM 12.1.2]
  c)  frequency of reporting to the contractor,  [UM 12.1.3]
  d)  process by which the contractor evaluates the delegated agency's performance; and  [UM 12.1.4]
  e)  remedies available to the contractor if obligations are not fulfilled by the delegated agency.  [UM 12.1.5]

2.  The contractor must maintain evidence that it:  [UM 12.2]
  a)  evaluates the agency's capacity to perform delegated activities prior to delegation;  [UM 12.2.1]
  b)  approves the agency's UM workplan and program description annually;  [UM 12.2.2]
  c)  evaluates annually whether delegated activities are conducted in accordance with the contractor's expectations and these standards  [UM 12.2.4]."  Washington Contract, QIP-2000 Standards, pages 17-18

"K.  DELEGATION OF CREDENTIALING  [CR 13]
If the contractor delegates any credentialing or recredentialing, the contractor must maintain evidence of oversight.
1.  The contractor must maintain a mutually agreed upon document, which describes:  [CR 13.1]
  a)  the responsibilities of the contractor and delegated agency;  [13.1.1]
  b)  the delegated activities;  [CR 13.1.2]
  c)  the process by which the contractor evaluates the delegated agency's performance; and  [CR 13.1.3]
  d)  remedies available to the contractor if obligations are not fulfilled by a delegated agency.  [CR 13.1.4]

2.  The contractor must retain the right to approve new practitioners, providers, and sites; and to terminate or suspend individual practitioners or providers based on quality issues.  [CR 13.3.1]

3.  There must be evidence that the contractor:  [CR 13.3]
  a)  evaluates the agency's capacity to perform delegated activities prior to delegation; and  [CR 13.3.1]
  b)  evaluates annually whether the delegated activities are conducted according to the contractor's expectations and these standards.  [CR 13.3.2]"  Washington Contract, QIP-2000 Standards, page 23.

"H.  DELEGATION of MEMBERS' RIGHTS and RESPONSIBILITIES [RR 8]
If the contractor delegates any member services activities, there must be evidence of oversight of the delegated activity.
1.  A mutually agreed upon document must describe:  [RR 8.1]
  a)  the responsibilities of the contractor and delegated agency;  [RR 8.1.1]
  b)  the delegated activities;  [RR 8.1.2]
  c)  the frequency of reporting to the contractor;  [RR 8.1.3]
  d)  the process by which the contractor evaluates the delegated agency's performance; and  [RR 8.1.4]
  e)  the remedies available to the contractor if the delegated agency does not fulfill its obligations.  [RR 8.1.5]

2.  The contractor must maintain evidence that it:  [RR 8.2]
  a)  evaluates the delegated agency's capacity to perform delegated activities prior to delegation;  [RR 8.2.1]
  b)  evaluates regular reports; and  [RR 8.2.2]
  c)  evaluates annually whether the delegated activities are being conducted in accordance with the contractor's expectations and these standards.  [RR 8.2.3]"  Washington Contract, QIP-2000 Standards, pages 30-31.

"D.  DELEGATION of MEDICAL RECORDS  [MR 4]
If the contractor delegates any medical record review activities, there must be evidence of oversight of the delegated activity.
1.  A mutually agreed upon document must describe:  [MR 4.1]
  a)  the responsibilities of the contractor and the delegated agency;  [MR 4.1.1]
  b)  the delegated activities;  [MR 4.1.2]
  c)  the frequency of reporting to the contractor;  [MR 4.1.3]
  d)  the process by which the contractor evaluates the delegated agency's performance; and  [MR 4.1.4]
  e)  the remedies available to the contractor if the delegated agency does not fulfill its obligations.  [MR 4.1.5]

2.  There must be evidence that the contractor:  [MR 4.2]
  a)  evaluates the delegated agency's capacity to perform the delegated activities prior to delegation;  [MR 4.2.1]
  b)  approves the delegated agency's medical records review work plan and procedures annually;  [MR 4.2.2]
  c)  evaluates regular reports as specified in MR 4.1; and [MR 4.2.3]
  d)  evaluates annually whether the delegated agency's activities are being conducted in accordance with the contractor's expectations and these standards.  [MR 4.2.4]"  Washington Contract, QIP-2000 Standards, pages 34-35.

WV

"3.25 Subcontracts
The Managed Care Plan may subcontract for any function covered by this contract, subject to the requirements of this contract…

The Managed Care Plan is required to give the Department prior notice with regard to its intent to subcontract out utilization review, and claims processing.  All subcontracts shall be in writing, shall include any general requirements of this contract that are appropriate tot he services being provided, and shall assure that all delegated duties of the Managed Care Plan under this contract are performed…"  West Virginia Contract, page 24.

"6.4  SUBCONTRACTS...
The Contractor may, with the prior written consent of the Department, enter into written subcontracts for performance of work under the Contract."  West Virginia RFA, page 63.

"6.10  CERTIFICATION RELATED TO LOBBYING...
The Contractor shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly."  West Virginia RFA, page 65.

"Standard VIII:  Delegation of QAP Activities
The plan remains accountable for all QAP functions, even if certain functions are delegated to other entities.  If the plan delegates any QA activities to contractors, the plan has the following oversight responsibilities.
A.  There is a written description of delegated activities, the delegate's accountability for these activities, and the frequency of reporting to the plan.
B.  The plan has written procedures for monitoring the implementation of the delegated functions and for verifying the actual quality of care being provided.
C.  There is evidence of continuous and ongoing evaluation of delegated activities, including approval of quality improvement plans and regular specified reports...

Standard XIII:  Utilization Review...
C.  Preauthorization and concurrent review - For plan with preauthroization or concurrent review programs: ...
7.  If the plan delegates responsibilities for utilization management, it has mechanisms to ensure that these standards are met my the delegate."  West Virginia RFA, Appendix E, pages E6, E16.

"IV-1  RESPONSIBILITY FOR ACTIVITIES DELEGATED TO OTHER ENTITIES
The MCO oversees and is accountable for any functions or responsibilities that are described in Domains I through III that are delegated to other entities.  All delegated functions must have a written agreement between the MCO and delegated entity, specifying the delegated activities and reporting responsibilities of the entity and providing for revocation of the delegation or other remedies for inadequate performance…If the MCO delegates selection of providers to another entity MCO must retain the right to approve, suspend, or terminate any provider selected by that entity."  West Virginia Contract, Exhibit F, page 17.

WI

"Y.  QUALITY IMPROVEMENT (QI)...
The HMO remains accountable for all QI functions, even if certain functions are delegated to other entities. If the HMO delegates any QI activities to contractors:

1)  There is a written description of: the delegated activities; the delegate's accountability for these activities; and the frequency of reporting to the HMO.
2)  The HMO has written procedures for monitoring and evaluating the implementation of the delegated functions and for verifying the actual quality of care being provided.
3)  There is evidence of continuous and ongoing evaluation of delegated activities, including approval of quality improvement plans and regular specified reports.
4)  There is evidence that HMO management representatives and providers participate in the development and implementation of the QI plan of the HMO. This provision shall not be construed to require that HMO management representatives and providers participate in every QI committee or subcommittee of the QI program...
9.  Utilization Management (UM)...
b. If the HMO delegates any part of the UM program to a third party, there must be a documented agreement, which includes a description of the delegated activities and reporting mechanisms for submitting data and information to the HMO.
c. The HMO must provide active oversight and evaluation of all aspects of performance of the delegated UM organization's activities, particularly in the area of provider and member satisfaction."  Wisconsin Contract, pages 21, 23, 28.

"AA. SUBCONTRACTS - Assure that all subcontracts shall be in writing, shall comply with the provisions of Addendum I, and shall include any general requirements of this Contract that are appropriate to the service or activity identified in Addendum I, and to assure that all subcontracts shall not terminate legal liability of the HMO under this Contract. The HMO may subcontract for any function covered by this Contract, subject to the requirements of this Contract."  Wisconsin Contract, page 32.

"ADDENDUM I
SUBCONTRACTS AND MEMORANDA OF UNDERSTANDING SUBCONTRACTS...
The Department will review and approve or disapprove each subcontract before contract signing… The Department's subcontract review will assure that the HMO has inserted the following standard language in subcontracts (except for specific provisions that are inapplicable in a specific HMO management subcontract): ...
a)  Subcontractor uses only Medicaid-certified- providers in accordance with Article III DD. of the Medicaid/HMO Contract.
(b)  No terms of this subcontract are valid which terminate legal liability of HMO in accordance with Article Ill. BB. of the Medicaid/HMO Contract.
c)  Subcontractor agrees to participate in and contribute required data to HMO Quality Improvement programs as required in Article III. Y. of the Medicaid/HMO Contract.
(d)  Subcontractor agrees to abide by the terms of the Medicaid/HMO Contract (Article III. E.) for the timely provision of emergency and urgent care. Where applicable, subcontractor agrees to follow those procedures for handling urgent and emergency care cases stipulated in any required hospital/emergency room MOUs signed by HMO in accordance with Article III. K. of the Medicaid/HMO Contract.
(e)  Subcontractor agrees to submit HMO recipient history/encounter data in the format specified by the HMO, so the HMO can meet the Department specifications required by Article VI and Addendum IV of the Medicaid/HMO Contract...
(f)  Subcontractor agrees to comply with all non-discrimination requirements...
(g)  Subcontractor agrees to comply with all record retention requirements and, where applicable, the special reporting requirements on abortions, sterilization's, hysterectomies, and HealthCheck requirements.
(h)  Subcontractor agrees to provide representatives of HMO, as well as duly authorized agents or representatives of DHFS and the Federal Department of Health and Human Services, access to its premises and its contract and/or medical records...
(i)  Subcontractor agrees to the requirements for maintenance and transfer of medical records...
(j)  Subcontractor agrees to ensure confidentiality of family planning services...
(k)  Subcontractor agrees not to create barriers to access to care by imposing requirements on recipients that are inconsistent with the provision of medically necessary and covered Medicaid benefits (e.g., COB recovery procedures that delay or prevent care).
(l)  Subcontractor agrees to clearly specify referral approval requirements to its providers and in any sub-subcontracts.
(m)  Subcontractor agrees not to bill a Medicaid enrollee for medically necessary services covered under the Medicaid/HMO Contract and provided during the enrollee's period of HMO enrollment...
(n)  Subcontractors must forward to the HMO medical records pursuant to grievances, within 15 working days of the HMO's request...
(o)  Subcontractor agrees to abide by the terms of Article III. I. regarding appeals to the HMO and to the Department for HMO non-payment of service providers.
(p)  Subcontractor agrees to abide by the HMO marketing/informing requirements...

The Department will also review HMO management subcontracts to assure that rates are reasonable.
(a)  Subcontracts for HMO management must clearly describe the services to be provided and the compensation to be paid.
(b) Any potential bonus, profit-sharing, or other compensation not directly related to costs of providing goods and services to the HMO, shall be identified and clearly defined in terms of potential magnitude and expected magnitude during the Medicaid/HMO Contract period.
c)  Any such bonus or profit-sharing shall be reasonable compared to services performed. The HMO shall document reasonableness.
(d)  A maximum dollar amount for such bonus or profit-sharing shall be specified for the contract period.
(e)  Requirements (a) through (d) do not have to relate to non-Medicaid enrollees 1f the HMO wishes to have separate arrangements for the Medicaid enrollees."  Wisconsin Contract, pages 72-74.

"PART B.  WISCONSIN MEDICAID HMO UTILIZATION DATA SET...
All HMO contracts with providers must have provisions for assuring that the data required on the HMO Utilization Report is reported to the HMO by the subcontractor. For example, subcontracts with providers of mental health or substance abuse services must have a provision ensuring that utilization data is reported to the HMO accurately and timely."  Wisconsin Contract, Addendum IV, page 90.