Medicaid Contract Purchasing SpecificationsPart 13Other Applicable Federal and State Requirements
§1301. General Requirements L(a) Audits of Services Performed — As required by §1903(m)(2)(A)(iv)(II) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(iv)(II), Contractor shall permit Purchaser, the Secretary of the Department of Health and Human Services, or any person or organization designated by the Secretary or the state agency, to audit and inspect and books and records of Contractor or of any subcontractor that pertain to the items or services performed or determinations of amounts payable under [drafter insert name of purchasing document]. HCFA distributed its Civil Rights Compliance Policy Statement in an August 3, 1998 letter to State Medicaid Directors. The Policy Statement stresses HCFA's commitment to "vigorously assur[ing] that all Medicare and Medicaid beneficiaries have equal access to and receive the best health care possible regardless of race, color, national origin, age, sex, or disability." (www.hcfa.gov/medicaid/smd8398.htm.) Subsection (b) is drafted, consistent with this policy statement, to protect Medicaid beneficiaries enrolled in MCOs from discrimination. L(b) Nondiscrimination1 (1) As required by §1903(m)(2)(A)(v) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(v), Contractor shall not discriminate among children who are eligible for Medicaid and who are eligible to enroll, reenroll, or disenroll with Contractor on the basis of their health status or their need for health services. (2) Contractor and providers participating in Contractor's provider network shall comply with the provisions of Title VI of the Civil Rights Act of 1964, 42 U.S.C. §2000d, 45 C.F.R. §80.1 et seq. (3) Contractor and providers participating in Contractor's provider network shall comply with the provisions of Title VII of the Civil Rights Act , 42 U.S.C. §2000e. (4) Contractor and providers participating in Contractor's provider network shall comply with the provisions of §504 of the Rehabilitation Act of 1973, 29 U.S.C. §794 et seq., 45 C.F.R. Part 85. (5) Contractor and providers participating in Contractor's provider network shall comply with the provisions of the Americans with Disabilities Act of 1990, 42 U.S.C. §12101 et seq., 28 C.F.R. Parts 35 and 36. (6) Contractor and providers participating in Contractor's provider network shall comply with the provisions of the Age Discrimination Act of 1975, 42 U.S.C. §6101 et seq., 45 C.F.R. Part 91. L(c) Disenrollment — In accordance with §203 of Part 2 and as required by §1903(m)(2)(A)(vi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(vi), Contractor shall allow a child who is eligible for Medicaid to disenroll for cause at any time and to disenroll without cause during the first 90 days following enrollment and at least every 12 months thereafter. L(d) Emergency services2 (1) Provision of Services — In accordance with §005(e) of the Overview and as required by §1903(m)(2)(A)(xi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi), Contractor shall: (A) provide coverage for emergency services (as defined in §1401(l)) under §1932(b)(2)(A)(i) of the Social Security Act, 42 U.S.C. §1396u-2(b)(2)(A)(i) without regard to prior authorization or whether Contractor has a relationship with a provider of such services; and (B) comply with the requirements of §1852(d)(2) and §1932(b)(2)(A)(ii) of the Social Security Act, 42 U.S.C. §1395w-22(d)(2) and §1396u-2(b)(2)(A)(ii), regarding coverage and coordination of post-stabilization care services. L(e) Financial Incentives Arrangements — In accordance with §004(c) of the Overview and as required by §1903(m)(2)(A)(x) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(x), Contractor shall comply with §1876(i)(8) of the Social Security Act, 42 U.S.C. §1395(i)(8) regarding compensation arrangements with physicians responsible for the care of Medicaid-eligible children that may directly or indirectly may induce a physician to reduce or limit medically necessary services to an enrolled child. L(f) Encounter Data — In accordance with §907 of Part 9 and as required by §1903(m)(2)(A)(xi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi), Contractor shall maintain sufficient encounter data to identify the physician (or other practitioner) who delivers services to a Medicaid eligible child. L(g) Unique Physician Identifier — In accordance with §512(a) of Part 5, As required by §1903(m)(2)(A)(xi), §1932(d)(4), §1902(a)(59), and §1902(x) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi), §1396u-2(d)(4), §1396a(a)(59), and §1396a(x), Contractor shall assign a unique identifier to each physician who furnishes care to a Medicaid eligible child under [drafter insert name of purchasing document]. L(h) Gag Rule Prohibited — In accordance with §1001 of Part 10 and as required by §1903(m)(2)(A)(xi) and §1932(b)(3) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi) and §1396u-2(b)(3), Contractor shall comply with prohibitions on interference with communications between health professionals and patients. L(i) Payment of FQHCs and RHCs — If a federally qualified health center (FQHC) or rural health center (RHC) participates in Contractor's provider network, Contractor shall, as required by §1903(m)(2)(A)(ix) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(ix),provide for payment to such FQHC or RHC that is not less than the level and amount of payment which Contractor would make for services if the services were furnished by a provider participating in Contractor's provider network other than an FQHC or an RHC. L(j) Provision of Information — In accordance with Part 3, and as required by §1903(m)(2)(A)(xi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi), Contractor shall provide, in an easily understood form to an enrolled child or the child's family or caregiver and potential enrolled children and their family or caregiver, all information that is required under §1932(a)(5)(B) of the Social Security Act, 42 U.S.C. §1396u-2(a)(5)(B), including the identity, locations, qualifications, and availability of providers participating in Contractor's provider network, rights and responsibilities of enrolled children, and information on covered items and services. L(k) Quality Assurance Standards — In accordance with Part 8, and as required by §1903(m)(2)(A)(xi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi), Contractor shall comply with the quality assessment and improvement strategy developed and implemented by Purchaser under §1932(c) of the Social Security Act, 42 U.S.C. §1396u-2(c). L(l) Prohibitions against Fraud and Abuse — As required by §1903(m)(2)(A)(xi) and §1932(d)(1) and (2) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi) and §1396u-2(d)(1) and (2), Contractor shall comply with the following requirements: (1) Contractor shall not enter into any employment or contractual agreement with an individual who is debarred, suspended or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in federal nonprocurement activities under federal regulations3; (2) Contractor shall not distribute directly or through an agent or independent contractor any materials without the prior approval of Purchaser and that contain false or misleading information4; (3) Contractor shall distribute marketing materials throughout its entire marketing area; and (4) Contractor shall not seek to influence an individual's enrollment in conjunction with the sale of any other product, engage in "cold call" or door-to-door marketing or engage in marketing fraud as defined in [drafter insert reference to applicable federal regulations]. L(m) Prohibition against Conflicts of Interest —As required by §1902(a)(4)(C) and §1932(d)(3) of the Social Security Act, 42 U.S.C. §1396a(a)(4)(C) and §1396u-2(d)(3), Contractor shall comply with the provisions prohibiting conflicts of interest involving state or local officials, employees, or independent contractors responsible for the expenditure of funds in connection with [drafter insert name of purchasing document]. L(n) Human Subject Research — Contractor and providers participating in Contractor's provider network shall comply with the applicable requirements of 45 C.F.R. Part 46 in conducting any research involving human subjects. (o) [drafter insert applicable state laws.] Endnotes
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Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under §1903(m) of the Social Security Act, 42 U.S.C. 1396b(m) relating to Medicaid MCOs . The illustrative language in this Part enumerates applicable federal or state law protections for state purchasers, the federal government, and enrolled children commonly found in Medicaid managed care contracts. As indicated by cross references, many of these statutory requirements are also integrated into the other Parts of these sample purchasing specifications. However, purchasers may wish to use this Part as a checklist for statutory references in developing Medicaid managed care purchasing documents.