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HomeMy WebLinkAboutDoc 748 - ABHA AgreementSERVICES AGREEMENT
BETWEEN
CENTRAL OREGON INDIVIDUAL HEALTH SOLUTIONS, INC.
AND
ACCOUNTABLE BEHAVIORAL HEALTH ALLIANCE
Commencement Date: January 1, 2011
Effective: January 1, 2011
Page 2 of 221
This Services Agreement (“Agreement”) is made and entered into effective as of January 1, 2011
(“Commencement Date”), by and between Central Oregon Individual Health Solutions, Inc., an Oregon
corporation (“COIHS”), and Accountable Behavioral Health Alliance, an Oregon ORS 190
intergovernmental Entity ("ABHA”).
WHEREAS, ABHA is an organization which previously contracted with the state of Oregon, acting
by and through its Department of Human Services (“DHS”), Division of Medical Assistance Programs
(“DMAP”), to implement and administer mental health services under the Oregon Health Plan for the
members of Benton, Crook, Deschutes (including 4 Klamath County zip codes), Jefferson, and Lincoln
counties, but has chosen, in the context of a demonstration project, to terminate its contract with the State of
Oregon for OHP mental health services delivered to the members of Crook, Deschutes and Jefferson
counties for the purposes described below, as well as in a separate Memorandum of Understanding signed by
COIHS, ABHA, and other organizations participating in the demonstration project;
WHEREAS, DHS views ABHA as one entity with one governing body, one budget, and that
ABHA’s internal business model, including any risk pooling from this demonstration project is a matter for
ABHA’s governing body to determine. ABHA’s member counties do not intend to create a new or separate
budget, risk pool or governing body by entering into this and related agreements;
WHEREAS, DHS, in the context of a demonstration project, shall redirect its contract for OHP
mental health services for the OHP members of Crook, Deschutes and Jefferson counties to COIHS;
WHEREAS, the Deschutes County Chemical Dependency Organization (“CDO”) has chosen, in the
context of a demonstration project, to terminate its contract with DHS for chemical dependency services for
the OHP members of Deschutes county, so DHS’s contract for chemical dependency services for the OHP
members of Deschutes county shall be redirected to COIHS for the purposes described below as well as in a
separate Memorandum of Understanding signed by COIHS, ABHA and other organizations participating in
the demonstration project;
WHEREAS, COIHS is a company contracted with the State of Oregon, acting by and through DHS
and DMAP, to implement and administer services, including chemical dependency services under the
Oregon Health Plan in certain counties in Oregon;
WHEREAS, ABHA understands that this Agreement is part of a demonstration project or integration
of physical health, mental health, and chemical dependency care in Central Oregon and if DHS determines,
in consultation with Local Mental Health Authorities, that the demonstration project is not achieving its
goals, DHS may elect to terminate or not renew for a future period its contract with COIHS. Such a
termination or non-renewal would lead to the termination of this Agreement by COIHS as detailed herein;
WHEREAS, ABHA is an independent mental health organization that has, as one of its objectives,
the delivery of mental health and chemical dependency treatment services in an efficient and cost-effective
manner to Oregon Health Plan members in Crook, Deschutes and Jefferson counties;
WHEREAS, ABHA has or will enter into contracts with Mental Health and Chemical Dependency
Providers and Facilities, all of whom are licensed, certified, or otherwise lawfully qualified to practice health
care in the state of Oregon;
WHEREAS, COIHS desires to enter into this Agreement with ABHA in order to obligate ABHA to
provide Covered Services, namely OHP mental health and chemical dependency services, hitherto referred to
as “behavioral health, to Oregon Health Plan Members residing in Service Area; and
Effective: January 1, 2011
Page 3 of 221
WHEREAS, the parties intend that should any reasonable ambiguity arise in the interpretation of a
provision of this Agreement, the provision shall be construed to be consistent with the legal requirements of
the Oregon Health Plan or other legal requirements, as applicable.
NOW, THEREFORE, in consideration of the mutual covenants and agreements, and subject to the
conditions and limitations set forth in this Agreement, and for the mutual reliance of the parties in this
Agreement, the parties hereby agree as follows
I. Service Area
For the purposes of this Agreement, ABHA's designated Service Area is within Jefferson, Deschutes
(including 4 Klamath county zip codes, as follows: 97731, 97733, 97737 and 97739) and Crook
Counties. ABHA shall serve, under the terms and conditions set forth in this Agreement, Oregon
Health Plan (OHP) Clients living in these counties who are enrolled with COIHS by DHS.
II. Remedial Action
As of the execution date of this Agreement, ABHA is subject to a Corrective Action Plan with AMH.
ABHA has represented that it expects to be fully compliant with the Corrective Action Plan as of the
effective date of this Agreement. If ABHA is not yet compliant with the Corrective Action Plan, then
it will continue to work with all haste to get into compliance. Further, ABHA agrees to indemnify
COIHS from any and all expenses, sanctions, losses, actions, claims, liabilities, and costs of any
nature whatsoever (including reasonable attorneys’ fees and expenses) related to the Corrective
Action Plan or work flowing there from.
III. Interpretation and Administration of Agreement
A. DHS has adopted reasonable and lawful policies, procedures, rules and interpretations to
promote orderly and efficient administration of this Agreement and the OHP plans in general.
The parties agree that both shall abide by all laws and Oregon Administrative Rules (OARs)
applicable to their performance under this Agreement.
B. In interpreting this Agreement, its terms and conditions shall be construed as much as possible
to be complementary, giving preference to this Agreement, (without exhibits, schedules or
attachments) over any exhibits, schedules or attachments. In the event of any conflict
between the terms and conditions of Exhibit D, and any other exhibit, schedule or attachment,
Exhibit D shall control. In the event of any conflict between the terms and conditions in any
other exhibits, schedules or attachments, the document earlier in the Table of Contents shall
control. In the event it is decided to look outside of this Agreement for purposes of
interpreting its terms, including its exhibits, schedules and attachments, COIHS will consider
only the following sources in the order of precedence listed:
1. The 2011 Oregon Health Plan Provider Services Contract Mental Health Organization,
Contract #132653, between COIHS and the State of Oregon (the “MHO Agreement”).
2. The 2011 Oregon Health Plan Provider Services Contract Fully Capitated Health Plan
Contract #132338, between COIHS and the State of Oregon (the “FCHP Agreement”).
Effective: January 1, 2011
Page 4 of 221
3. The Grant Award Letters from the Centers for Medicare and Medicaid Services
(CMS) for operation of the Oregon Reform Demonstration (Oregon Health Plan
Medicaid and State Children’s Health Insurance Program Demonstration Project
(SCHIP )), and the Health Insurance Flexibility and Accountability (HIFA)
demonstration, including all special terms and conditions and waivers.
4. The Federal Medicaid Act, Title XIX of the Social Security Act, and its implementing
regulations, published in the Code of Federal Regulations (CFR), the HIFA
demonstration, and SCHIP, established by Title XXI of the Social Security Act, except
as waived by CMS for the Oregon Health Plan Medicaid and State Children’s
Insurance Program Demonstration Project, as amended and as administered in Oregon
by DHS.
5. The Oregon Revised Statutes (ORS) concerning the OHP.
6. The Oregon Administrative Rules (OAR) related to the OHP concerning mental health
Services promulgated by DHS.
7. Other applicable ORS’ and OAR’s concerning the Medical Assistance Program under
prepaid capitated plans, Fee-For-Service (FFS) arrangements and mental health
Services.
8. Other applicable Oregon statutes and DHS administrative rules concerning mental
health Services.
9. The document titled "Memorandum of Understanding -- Central Oregon Health
Integration Project" signed by the parties on ___/___/_____; the letter of intent from
Ken Provencher on behalf of Clear One Health Plans, Inc., a PacificSource Company,
dated August 27, 2010; the Central Oregon Regional Health Authority, dated
September 7, 2010; and the Letter of Understanding regarding Medicaid/CHIP
Managed Care Contract Changes for the Central Oregon Health Integration Project,
dated September 9, 2010.
C. If ABHA believes that any provision of this Agreement or COIHS’s interpretation thereof, is
in conflict with federal or state statutes or regulations, ABHA shall notify COIHS in writing
immediately.
Any provision of this Agreement which is in conflict with Federal Medicaid and SCHIP
statutes, regulations, or CMS policy guidelines shall be amended to conform to the provision
of those laws, regulations and federal policy.
D. The initial step with respect to all claims or controversies concerning this Agreement, or
arising in any way out of the performance of this Agreement, shall be a meeting of senior
executives for each party. Such meeting shall be held as quickly as possible, when an
impasse is reached by the representatives of each party having day-to-day responsibility for
this Agreement. The parties shall meet and seek to resolve any such claim or controversy in
good faith. If such meeting does not resolve the situation, then the sole remedy of the parties
with respect to all claims or controversies concerning this Agreement, or arising in any way
out of the performance of this Agreement, shall be binding arbitration by a single arbitrator in
accordance with the commercial arbitration rules of the American Arbitration Association,
Effective: January 1, 2011
Page 5 of 221
following its Health Forum rules, who shall have the discretion to award to the prevailing
party, if any, that party’s attorneys’ fees and costs or otherwise apportion the parties’
attorneys’ fees and costs between them as part of the arbitrator’s decision. Notwithstanding
the foregoing, neither COIHS nor ABHA shall be required to participate in any arbitration
proceedings under this Agreement relating to any professional liability claim if such
participation would violate the terms and conditions of the professional liability coverage of
COIHS or ABHA. Such arbitration shall be held in Deschutes County, Oregon, unless the
parties mutually agree to another location. Nothing herein shall prohibit a party from seeking
equitable relief in a court of law to maintain the status quo while the arbitration is pending.
IV. Government Status
As an intergovernmental entity formed under the statutory authority of ORS Chapter 190, ABHA has
governmental status. ABHA certifies that it is not currently employed by the federal government to
provide the work covered by this Agreement. ABHA certifies that ABHA is not an employee of the
State of Oregon.
V. ABHA Data and Certification
A. ABHA Insurance Information. This information is requested pursuant to ORS 305.385 and
OAR 125-246-0333(5).
Please print or type the following information
If ABHA is self-insured for any of the Insurance Requirements specified in Exhibit F of this
Agreement, ABHA may so indicate by: (i) writing “Self-Insured” on the appropriate line(s);
and (ii) submitting a certificate of insurance as required in Exhibit F, Section 6.
NAME (exactly as filed with the IRS):
Address:
Telephone: ( ) Facsimile Number: ( )
Proof of Insurance:
Workers Compensation – Insurance Company
Policy
Expiration Date:
Professional Liability Insurance Company
Policy # Expiration Date:
General Liability Insurance Company
Policy # Expiration Date:
Auto Insurance Company
Policy # Expiration Date:
The above information must be provided prior to Agreement execution. ABHA shall provide
proof of Insurance upon request by COIHS.
B. Certification. By signature on this Agreement, the undersigned hereby certifies under penalty
of perjury that:
Effective: January 1, 2011
Page 6 of 221
1. The undersigned is authorized to act on behalf of ABHA and that ABHA is, to the best
of the undersigned's knowledge, not in violation of any Oregon Tax Laws. For
purposes of this certification, "Oregon Tax Laws" means a state tax imposed by ORS
403.200 to 403.250 (Tax for Emergency Communications), 118 (Inheritance Tax), 314
(Income Tax), 316 (Personal Income Tax), 317 (Corporation Excise Tax), 318
(Corporation Income Tax), 320 (Amusement Device and Transient Lodging Taxes),
321 (Timber and Forestland Tax), 323 (Cigarettes and Tobacco Products Tax), and the
elderly rental assistance program under ORS 310.630 to 310.706; and any local taxes
administered by the Department of Revenue under ORS 305.620;
2. The information shown in Part V, Section A. “ABHA Data and Certification” above is
ABHA's true, accurate and correct information;
3. ABHA is not subject to backup withholding because:
a. ABHA is exempt from backup withholding;
b. ABHA has not been notified by the IRS that ABHA is subject to backup
withholding as a result of a failure to report all interest or dividends; or
c. The IRS has notified ABHA that ABHA is no longer subject to backup
withholding; and
4. ABHA is an independent contractor as defined in ORS 670.600.
5. ABHA is required to provide its Federal Employer Identification Number (FEIN) or
Social Security Number (SSN). By ABHA’s signature on this Agreement, ABHA
hereby certifies that the FEIN or SSN provided on the CTII form is true and accurate.
If this information changes, ABHA is also required to provide COIHS with the new
FEIN or SSN within 10 days.
ABHA, BY EXECUTION OF THIS AGREEMENT, HEREBY ACKNOWLEDGES THAT ABHA HAS
READ THIS AGREEMENT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
BY EXECUTION OF THIS AGREEMENT, I, AN AUTHORIZED OFFICIAL OF ABHA CERTIFY
THAT ALL DATA, CLAIMS SUBMISSIONS OR OTHER SUBMISSIONS THAT PROVIDE A BASIS
FOR CAPITATION PAYMENTS ARE TRUE, ACCURATE AND COMPLETE; AND ACKNOWLEDGE
THAT PAYMENT OF CLAIMS AND CAPITATION PAYMENTS WILL BE FROM FEDERAL AND
STATE FUNDS, AND THAT THEREFORE ANY FALSIFICATION, OR CONCEALMENT OF A
MATERIAL FACT WHEN SUBMITTING CLAIMS OR OTHER SUBMISSIONS TO OBTAIN
PAYMENTS, MAY BE PROSECUTED UNDER FEDERAL AND STATE LAWS.
VI. Signatures
In witness, the parties listed below have caused this Agreement to be executed by their duly
authorized officers as of the date first set forth above.
Effective: January 1, 2011
Page 7 of 221
COIHS: ABHA:
Central Oregon Individual Accountable Behavioral Health Alliance
Health Solutions, Inc.
By: By:
Name: Name:
Title: Title:
Date: ______________________ Date:
By:
Name:
Title:
Date:
By:
Name:
Title:
Date:
By:
Name:
Title:
Date:
By:
Name:
Title:
Date:
Tax ID No. ____-___________
Address: Address:
Central Oregon Individual Accountable Behavioral Health Alliance
Health Solutions, Inc. ______________________________
P.O. Box 7469 ______________________________
Bend, OR 97708 ______________________________
Attn: Senior Vice President Attn:
Effective: January 1, 2011
Exhibit A Page 8 of 221
EXHIBIT A – Definitions
In addition to any terms that may be defined elsewhere in this Agreement and with the following exceptions
and additions, the terms in this Agreement have the same meaning as those terms appearing in Oregon
Administrative Rules (OARs) 309-012-0140, 309-032-0180, 309-032-0860, 309-032-1505, 309-033-0210,
410-120-0000, and 410-141-0000. The order of preference for interpreting conflicting definitions is this
Agreement, the MHO Agreement, the FCHP Agreement, Oregon Health Plan Rules of DHS, General Rules
of DHS, and Mental Health Rules of DHS. The following terms shall have the following meanings below
when capitalized:
1. “ABHA Representative” means the individual within ABHA organization responsible for handling
Grievance issues. The role of this person is described in Exhibit N, Grievance System.
2. “Abuse” means any death caused by other than accidental or natural means; any physical injury
caused by other than accidental means or that appears to be at variance with the explanation given of
the injury; willful infliction of physical pain or injury; and sexual harassment or exploitation,
including but not limited to, any sexual contact between an employee of a facility or community
program and an OHP Member. In residential programs, Abuse includes other intentional acts or
absence of action that interfere with the mental, emotional or physical health of the resident.
3. “Action” means in the case of ABHA, (1) the denial or limited authorization of a requested Covered
Service, including the type or level of service, (2) the reduction, suspension or termination of a
previously authorized service, (3) the denial in whole or in part, of payment for a service, (4) failure
to provide services in a timely manner, (5) the failure of ABHA to act within the timeframes provided
in 42 CFR 438.408(b), or (6) for a OHP Member who resides in a rural Service Area where ABHA is
the only Mental Health Organization, the denial of a request to obtain Covered Services outside of
ABHA’s Participating Provider panel pursuant to OAR 410-141-0160 and 410-141-0220.
4. “Acute Care” means intensive, psychiatric services provided on a short-term basis to a person
experiencing significant symptoms of a mental disorder that interfere with the person's ability to
perform activities of daily living.
5. “Acute Inpatient Hospital Psychiatric Care” means Acute Care provided in a psychiatric hospital
with 24-hour medical supervision.
6. “Addictions and Mental Health Division” or “AMH” means the DHS office responsible for the
administration of the state’s policy and programs for mental health, chemical dependency,
Prevention, intervention, and treatment services.
7. “Adjudicate” means ABHA’s determination that an OHP Member’s Claim for services is either;
fully or partially accepted as ABHA’s liability, not accepted for any liability, lacks enough
information or valid information to make a determination or has the need for additional information
in order for ABHA to determine ABHA’s liability.
8. “Adjustment” means the submission of a replacement Encounter Claim by the ABHA to an
Encounter Claim the ABHA previously submitted for the same OHP Member, same service and same
date of service to make modifications to other data elements contained within the Encounter Claim
except when the Adjudicated status changes from either accepted liability to reject liability or vice
versa.
Effective: January 1, 2011
Exhibit A Page 9 of 221
9. “Administrative Hearing” means a DHS hearing related to an Action, including a denial, reduction,
or termination of benefits that is held when requested by the OHP Member or OHP Member
Representative. An Administrative Hearing may also be held when requested by an OHP Member or
OHP Member Representative who believes a claim for Services was not acted upon with reasonable
promptness or believes the payer took an Action erroneously.
10. “Adult Mental Health Initiative” or “AMHI” means an initiative that is designed to promote more
effective Utilization of current capacity in facility based Treatment Settings, increase care
coordination and increase accountability at a local and state level. It is also designed to promote the
availability and quality of individualized community-based Services and supports so that adults with
mental illness are served in the least restrictive environment possible and use of long term
institutional care is minimized.
11. “AMH Representative” means the individual within DHS designated to handle Administrative
Hearings requested by OHP Members or OHP Member Representative. The role of AMH
Representative is described in Exhibit N, Grievance System.
12. “Allied Agencies” means, local and regional governmental agencies and regional authorities that
contract with DHS to provide the delivery of services to covered individuals, (e.g., LMHAs, CMHPs,
Oregon Youth Authority (OYA), Department of Corrections, local health departments, schools,
education service districts, developmental disability service programs, area agencies on aging, SPD,
DHS Rehabilitation Services under the Community Services Program, housing authorities, local
schools, special education, law enforcement agencies, adult criminal justice and juvenile justice,
developmental disability services, Chemical Dependency Providers, residential providers, Oregon
State Hospital, Prepaid Health Plans and federally recognized American Indian tribes).
13. “Appeal” means a request by an OHP Member or OHP Member Representative, or by a Provider
acting on behalf of the OHP Member with the OHP Member’s written consent, for COIHS to review
an Action as defined in this Exhibit.
14. “Assessment” means the determination of a person's need for Covered Services. It involves the
collection and evaluation of data pertinent to the person's mental history and current problem(s)
obtained through interview, observation, and record review. The Assessment concludes with one of
the following: (1) documentation of a DSM Diagnosis providing the clinical basis for a written
Treatment Plan; or (2) a written statement that the person is not in need of Covered Services. Other
disposition information such as to whom the person was referred is included in the Clinical Record.
15. “Atypical Providers” means an entity able to enroll as a billing provider or performing provider for
medical assistance programs related non-health care services but which does not meet the definition
for health care provider for NPI purposes.
16. “Behavioral Health” means a reference to clinical services provided to OHP Members which
constitute Mental Health Services, Chemical Dependency Services or both.
17. “Capacity” means the ability to make Covered Services available in a given geographic area relative
to the size, location and unique needs of the OHP Membership within it. Indicators of Capacity may
be represented as ratios between the number of Participating Providers per 1,000 OHP Members for a
given geographic area (county or zip code); as ratios between the number of Participating Providers
per 1,000 OHP Members; as ratios between various types of Participating Providers (psychiatrists,
case managers) per a set number of OHP Members with specific diagnoses, unique characteristics
and/or special needs; as ratios between the number of Participating Providers per the total of OHP
Effective: January 1, 2011
Exhibit A Page 10 of 221
Members and other patients; as a function of travel time or distance between the OHP Member’s
residence and the Participating Provider; as a function of waiting time for regular appointments,
Urgent Care, emergency care and specialty care; as a function of office waiting time; and as a
function of 24-hour care. Measurement of Capacity must consider factors such as geographic or
physical barriers (mountains or rivers) which preclude access, service Utilization patterns (services
being sought outside the immediate vicinity), language or cultural barriers, and needs of migrant or
seasonal workers.
18. “Capitation” means a payment model which is based on prospective payment for services,
irrespective of the actual amount of services provided, generally calculated on a per OHP Member
per month basis.
19. “Capitation Payment” means a monthly prepayment to ABHA for the provision of capitated
services provided on behalf of OHP Members. Capitation Payment is made on a per OHP Member,
per month basis.
20. “Case Management” means services provided to OHP Members who require assistance to ensure
access to benefits and services from Allied Agencies or other service Providers. Case Management
services includes: advocating for the OHP Member's treatment needs; providing assistance in
obtaining entitlements based on mental or emotional disability; referring OHP Members to needed
services or supports; accessing housing or residential programs; coordinating services including
mental health treatment, educational or vocational activities; and arranging alternatives to inpatient
hospital services.
21. “Case Rate” means a flat rate paid per OHP Member for a specific range of services. A Case Rate
may be paid for each referral made to a Provider or for each admission made to a hospital. The
Provider receiving the payment assumes the risk of providing all Covered Services for the full range
of services for each OHP Member for whom the payment was made.
22. “CCC Chairperson” means a QMHP with experience in children's mental health treatment
designated by the CMHP director in each county to coordinate LTPC screenings.
23. “Chemical Dependency Provider” means a practitioner approved by DHS to provide publicly
funded alcohol and drug abuse Rehabilitative Services.
24. “Chemical Dependency Services” means assessment, treatment and rehabilitation on a regularly
scheduled basis, or in response to crisis for alcohol and/or other drug abusing or dependent clients
and their family members or significant others that are consistent with Level I or Level II of ASAM
PPC 2R patient placement criteria.
25. “Civil Commitment” means the legal process of involuntarily placing a person, determined by the
Circuit Court to be a mentally ill person as defined in ORS 426.005 (1) (d), in the custody of DHS.
DHS has the sole authority to assign and place a committed person to a treatment facility. DHS has
delegated this responsibility to the CMHP Director. Civil Commitment does not automatically allow
for the administration of medication without informed client consent. Additional procedures
described in administrative rule must be followed before medication can be involuntarily
administered.
26. “Claim” means 1) a bill for services, 2) a line item of service or 3) all services for one recipient
within a bill.
Effective: January 1, 2011
Exhibit A Page 11 of 221
27. “Clean Claim” means a Claim that can be processed without obtaining additional information.
28. “Client Process Monitoring System” or “CPMS” means the automated consumer data system
maintained by DHS.
29. “Clinical Reviewer” means the entity jointly chosen to resolve disagreements related to an OHP
Member's need for LTPC immediately following an Acute Inpatient Hospital Psychiatric Care stay.
30. “Clinical Record” means a collection of all documentation regarding a Consumer’s mental health
Treatment and related services. For the purpose of confidentiality, it is considered the medical record
defined in ORS Chapter 179.
31. “Clinical Services Coordination” means coordinating the access to, and provision of, services from
multiple agencies according to the Treatment Plan; establishing crisis service linkages; advocating for
the OHP Member's treatment needs; and providing assistance to obtaining entitlements based on
mental or emotional disability.
32. “Community Coordinating Committee” or “CCC” means a committee composed of
representatives from the local CMHP, DHS Children, CAF, Juvenile Court, local education district,
and the AMH Child and Adolescent Mental Health Specialist.
33. “Community Coordinating Committee (CCC) Care Path Plan” means a written plan for
discharge to a least restrictive appropriate setting with specific discharge criteria. Discharge criteria
are linked to resolution of symptoms and behaviors that justified admission to LTPC. The CCC Care
Path Plan provides an opportunity for those parties most familiar with the treatment needs of the child
to develop a care path plan.
34. “Community Emergency Service Agencies” means, but are not limited to, hospital emergency
rooms, crisis centers, protective services of DHS, OYA, local juvenile justice, police, homeless
shelters, CMHPs, and Civil Commitment investigators.
35. “Community Mental Health Program” or “CMHP” means the organization of all services for
persons with mental or emotional disorders and developmental disabilities operated by, or
contractually affiliated with, a LMHA, operated in a specific geographic area of the state under an
intergovernmental agreement or direct contract with DHS.
36. “Community Standard” means the typical expectations for access to the health care delivery system
in the OHP Member’s community of residence. Except where the Community Standard is less than
sufficient to ensure Quality of Care, DHS requires that the health care delivery system available to
OHP Members take into consideration the Community Standard and be adequate to meet the needs of
OHP Members.
37. “Condition/Treatment Pair” means the diagnoses described in the International Classification of
Diseases Clinical Modifications, 9th edition (ICD-9 CM), the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition (DSM-IV) and treatments described in the Current Procedural
Terminology, 4th edition (CPT-4), HCPC, and BA/ECC Codes established by DHS or the AMH
Medicaid Procedure Codes and Reimbursement Rates, which, when paired by the Health Services
Commission (HSC), constitute the line items in the Prioritized List of Health Services.
Condition/Treatment Pairs are referred to in OAR 410-141-0520.
Effective: January 1, 2011
Exhibit A Page 12 of 221
38. “Consultation” means professional advice or explanation given concerning a specific OHP Member
to others involved in the treatment process, including Family members, staff members of other
human services agencies (such as DHS, schools, OYA, juvenile justice) and care providers (such as
Nursing Homes, foster homes, or residential care facility staff).
39. “Consumer” means an OHP Member with a mental or emotional disorder who receives Covered
Services. This term is also used in reference to any person receiving services through a CMHP which
are not Covered Services.
40. “Continuity of Care” means the ability to sustain services necessary for a person's treatment.
Continuity of Care is a concern when an OHP Member is transferred from one service provider to
another.
41. “Corrective Action” or Corrective Action Plan” means a requirement for ABHA or subcontractor
to develop and implement a time specific plan, for the correction of COIHS identified areas of non-
compliance, as described in this Agreement.
42. “Covered Services” means services that are included in the Capitation Payment paid to ABHA
under this Agreement with respect to an OHP Member under this Agreement whenever services are
Medically Appropriate for the OHP Member. Services included in the Capitation Payment are
described in the State of Oregon, Oregon Health Plan Service Categories for Per Capita Costs,
October 2002 through September 2003. The Capitation Payment is based on the number of
Condition/Treatment Pair lines of the List of Prioritized Health Services funded by the Legislature
and adopted in OAR 410-141-0520. The Covered Services described in this Agreement shall be
substituted with and/or expanded to include Flexible Services and Flexible Service Approaches
identified and agreed to by ABHA, the OHP Member and, as appropriate, the Family of the OHP
Member as being an efficacious alternative. Covered Services are limited in accordance with OAR
410-141-0500, Excluded Services and Limitations for OHP Clients.
43. “Culturally Competent” means the Capacity to provide services in an effective manner that is
sensitive to the culture, race, ethnicity, language and other differences of an individual. Such services
may include, but are not limited to, use of bilingual and bicultural staff, provision of services in
culturally appropriate alternative settings, and use of bicultural Paraprofessionals as intermediaries
with professional staff.
44. “Current Procedural Terminology” or “CPT” means a listing of descriptive terms and identifying
codes for reporting medical services and procedures performed by physicians. The purpose of the
terminology is to provide a uniform language that accurately describes medical, surgical, and
diagnostic services, and thereby provides an effective means for reliable nationwide communication
among physicians, patients, and third parties.
45. “Declaration for Mental Health Treatment” means a written statement of a person's decisions
concerning his or her mental health treatment. The declaration is made when the person is able to
understand and make decisions related to such treatment. It is honored when the person is unable to
make such decisions.
46. “Diagnosis” or “DSM Diagnosis” means the principal mental disorder listed in the most recently
published edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) that is the
Medically Appropriate reason for clinical care and the main focus of treatment for an OHP Member.
The Principal Diagnosis is determined through the mental health Assessment and any examinations,
tests, procedures, or Consultations suggested by the Assessment. Neither a DSM "V" code disorder,
Effective: January 1, 2011
Exhibit A Page 13 of 221
substance use disorder or mental retardation may be considered the Principal Diagnosis, although
these conditions or disorders may co-occur with the diagnosable mental disorder.
47. “Disenrollment” means the act of discharging an OHP Member from a DHS contractor’s
responsibility under this Agreement. After the effective date of Disenrollment an OHP Client is no
longer required to obtain Covered Services from the DHS contractor, nor be referred by the DHS
contractor.
48. “DSM Code” means the numerical code, including modifiers, which identifies psychiatric disorders
defined in the most recent American Psychiatric Association’s Diagnostic and Statistical Manual.
49. “Early Intervention” means the Provision of Covered Services directed at preventing or
ameliorating a mental disorder or potential disorder during the earliest stages of onset or prior to
onset for individuals at high risk of a mental disorder.
50. “Emergency Psychiatric Hold” means the physical retention of a person taken into custody by a
peace officer, health care facility, OSH, hospital or nonhospital facility as ordered by a physician or a
CMHP director, pursuant to ORS Chapter 426,.
51. “Emergency Response System” means the coordinated method of triaging the mental health service
needs of OHP Members and providing Covered Services when needed. The system operates 24-
hours a day, 7-days a week and includes, but is not limited to, after hours on call staff, telephone and
in person screening, Outreach, and networking with hospital emergency rooms and police.
52. “Emergency Service” means inpatient or outpatient Covered Services furnished by a Provider that is
qualified to furnish these Services and that are needed to evaluate or stabilize an Emergency
Situation. See definition for Twenty-four (24) Hour Urgent and Emergency Services.
53. “Emergency Situation” means a mental health condition manifesting itself by acute symptoms of
sufficient severity such that a prudent layperson, with an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy
to the health of the OHP Member, (or, with respect to a pregnant woman, the health of the woman or
her unborn child) (2) serious impairment of bodily function, or (3) serious dysfunction of any bodily
organ or part. An “Emergency Medical Condition” is determined based on the presenting symptoms
(not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional)
and includes cases in which the absence of immediate medical attention would not in fact have had
the adverse results described in the previous sentence.
54. “Encounter” means an outpatient contact or Acute Inpatient Hospital Psychiatric Care admission for
Covered Services provided to an OHP Member.
55. “Encounter Data” means health care Claims or equivalent Encounter information transaction
transmitting either of the following:
a. A request to obtain payment, and the necessary accompanying information from a Provider to
ABHA, for health care,
b. A Claim to demonstrate the provision of Services for other compensation as established
between ABHA and Provider, or
Effective: January 1, 2011
Exhibit A Page 14 of 221
c. If there is no direct Claim, because the reimbursement contract is based on a mechanism other
than charges or reimbursement rates for specific Services, the transaction of Encounter
information for reporting ABHA’s health care.
56. “Enhanced Care Services” means services, which are not Covered Services, defined in OAR 309-
032-1500 through 309-032-1540 as provided to eligible persons who reside at facilities licensed by
Senior and Disabled Services now referred to as Seniors and People with Disabilities Division.
57. “Enrollment” means the assignment of OHP Clients to DHS contractors per OAR 410-141-0060,
Oregon Health Plan Managed Care Enrollment Requirements. Once the OHP Client becomes an
OHP Member, the person must receive all Covered Services from the DHS contractor or be referred
by the DHS contractor to Mental Health or Chemical Dependency Treatment Providers.
58. “Evaluation” means a psychiatric or psychological Assessment used to determine the need for
mental health services. The Evaluation includes the collection and analysis of pertinent
biopsychosocial information through interview, observation, and psychological and
neuropsychological testing. The Evaluation concludes with a five axes Diagnosis of a DSM
multiaxial Diagnosis, prognosis for rehabilitation, and treatment recommendations.
59. “Extended Care Management” means overseeing the Utilization of extended care resources.
60. “Extended Care Management Unit” or “ECMU” means the unit within AMH responsible for
providing the clinical Assessment, Consultation, and placement of adults age 18 to 64 with severe
and persistent mental illness who require long term structure, support, rehabilitation, and supervision
within designated Extended Care Projects; the Utilization review of those projects and the screening
of all requests for admission to LTPC.
61. “Extended Care Project” means a State-funded program designed to provide necessary services for
adults in a least restrictive environment, utilizing a range of hospital, residential, and community
resources. These programs include secure residential facilities, residential psychiatric treatment, Post
Acute Intermediate Treatment Services (PAITS) programs, Geropsychiatric Treatment Program at
OSH, DHS Seniors and People with Disabilities Program enhanced care and PASSAGES Projects,
“365” Plans, Psychiatric/Vocational Projects and enhanced foster care programs.
62. “Family” means parent or parents, legal guardian, siblings, grandparents, spouse and other primary
relations whether by blood, adoption, legal or social relationship.
63. “Flexible Service” means a service that is an alternative or addition to a Traditional Service that is as
likely or more likely to effectively treat the mental disorder as documented in the OHP Member’s
Clinical Record. Flexible Services may include, but are not limited to: Respite Care, Partial
Hospitalization, Subacute Psychiatric Care, Family Support Services, Parent Psychosocial Skills
Development, Peer Counseling, and other non-Traditional Services identified.
64. “Flexible Service Approach” means the delivery of any Covered Service in a manner or place
different from the traditional manner or place of service delivery. A Flexible Service Approach may
include delivering Covered Services at alternative sites such as schools, residential facilities, nursing
facilities, OHP Members' homes, emergency rooms, offices of DHS, other community settings;
offering flexible clinic hours; offering Covered Services through Outreach or a home-based
approach; and using peers, Paraprofessionals and persons who are Culturally Competent to engage
difficult-to-reach OHP Members.
Effective: January 1, 2011
Exhibit A Page 15 of 221
65. “Geropsychiatric Treatment Service” or “OSH-GTS” means four units at OSH serving frail
elderly persons with mental disorders, head trauma, advanced dementia, and/or concurrent medical
conditions who cannot be served in community programs.
66. “Grievance” means an OHP Member's or OHP Member Representative's expression of
dissatisfaction to ABHA or to a Participating Provider about any matter other than an Action.
67. “Grievance System” means the overall system that includes Grievances and Appeals handled by
ABHA (grievances) and COIHS (appeals) and access to the State fair hearing process. (Possible
subjects for Grievances include, but are not limited to, the quality of care or services provided and
aspects of interpersonal relationships such as rudeness of a Provider or employee, or failure to respect
the OHP Member's rights.)
68. “Health Care Professional” means a person with current and appropriate licensure, certification, or
accreditation in a medical, mental health or dental profession, which include but are not limited to:
medical doctors (including psychiatrists), osteopathic physicians, psychologists, registered nurses,
nurse practitioners, licensed practical nurses, certified medical assistants, licensed physician
assistants, QMHAs, QMHPs, dentists, dental hygienists, denturists, and certified dental assistants.
69. “Health Services Commission” or “HSC” means the governing body responsible for the OHP
which determines the Condition/Treatment Pairs to be included on the Prioritized List of Health
Services and determines the ranking of each pair.
70. “Incurred But Not Reported or IBNR Expenses” means expenses for services authorized by an
agency responsible for their payment, but for which no statement has yet been received by that
agency. These are expenses for which the agency is liable and which the agency will need to expect
to pay.
71. “Indian Health Care Provider” means an Indian Health Program or an Urban Indian Organization.
72. “Indian Health Program” means an Indian Health Service facility, any federally recognized tribe or
tribal organization or any tribe 638 Federally Qualified Health Center (FQHC) enrolled with DHS as
an American Indian/Alaska Native (AI/AN) provider.
73. “Intake” means the process of gathering preliminary information about a potential Consumer to
determine whether the person is eligible for services, the urgency of the situation or need for services,
and the initial provisional Diagnosis. This information is used to schedule the first appointment, if
applicable.
74. “Integrated Services Array” or “ISA” means a range of service components that are coordinated,
comprehensive, Culturally Competent, and include intensive and individualized home and
community-based services for children and adolescents with severe mental or emotional disorders
whose needs have not been adequately addressed in traditional Settings. The ISA integrates
inpatient, psychiatric residential and Psychiatric Day Treatment and community-based care provided
in a way to ensure that children and adolescents are served in the most natural environment possible
and that the use of institutional care is minimized. The intensity, frequency, and blend of these
services are based on the mental health needs of the child.
75. “Intensive Psychiatric Rehabilitation” means the application of concentrated and exhaustive
treatment for the purpose of restoring a person to a former state of mental functioning.
Effective: January 1, 2011
Exhibit A Page 16 of 221
76. “Involuntary Psychiatric Care” means any psychiatric service, such as forced medication, which is
provided on a basis other than by informed client (or guardian) consent. Involuntary psychiatric
services are provided only when authorized by ORS Chapter 426 and in accordance with
administrative rules. Generally, a person must be determined to lack the capacity to give informed
client consent before involuntary psychiatric services may be administered.
77. “Licensed Medical Practitioner” or “LMP” means a person who is a physician, nurse practitioner
or physician's assistant licensed to practice in the State of Oregon whose training, experience and
competence demonstrates the ability to conduct a comprehensive mental health Assessment and
provide Medication Management. The Local Mental Health Authority (LMHA) or ABHA must
document that the person meets these minimum qualifications.
78. “Local Mental Health Authority” or “LMHA” as defined in ORS 430.630, means the county court
or board of commissioners of one or more counties who choose to operate a CMHP; or, if the county
declines to operate or contract for all or part of a CMHP, the board of directors of a public or private
corporation which contracts with DHS to operate a CMHP for that county.
79. “Long-Term Psychiatric Care” or “LTPC” means inpatient psychiatric services delivered in an
Oregon State operated Hospital after Usual and Customary care has been provided in an Acute
Inpatient Hospital Psychiatric Care Setting or The Joint Commission (TJC) Residential Psychiatric
Treatment Center for children under age 18 and the individual continues to require a hospital level of
care.
80. “MHO Exceptional Needs Care Coordination (ENCC) Services” means services as specified in
OAR 410-141-0000 (51) (a) - (e) provided to those OHP Members in the custody of Child Welfare,
having complex medical needs and receiving services under the Children's Wraparound
Demonstration Project.
81. “Marketing” means any communication, from ABHA to an OHP Client who is not enrolled with
ABHA, that can reasonably be interpreted as intended to influence the OHP Client to enroll with
COIHS, or either to not enroll in, or to disenroll from, another MHO or Managed Care Organization.
82. “Marketing Materials” means any medium produced by, or on behalf of, a PHP that can reasonably
be interpreted as intended for Marketing as defined in OAR 410-141-0000.
83. “Medicaid” means the federal and state funded portion of the Medical Assistance Program
established by Title XIX of the Social Security Act, as amended, and administered in Oregon by
DHS.
84. “Medical Assistance Program” means a DHS program for payment of medical and remedial care
provided to eligible Oregonians that is administered by identified programs, services, and operations
within DHS. DHS has primary responsibility for coordinating the Medical Assistance Program.
85. “Medically Appropriate” means services and supplies which are required for Prevention (including
preventing a relapse), Diagnosis or Treatment of mental disorders and which are appropriate and
consistent with the Diagnosis; consistent with treating the symptoms of a mental illness or treatment
of a mental disorder; appropriate with regard to standards of good practice and generally recognized
by the relevant scientific community as effective; not solely for the convenience of the OHP Member
or provider of the service or supply.
Effective: January 1, 2011
Exhibit A Page 17 of 221
86. “Medication Override Procedure” means the administration of psychotropic medications to a
person in an Acute Inpatient Hospital Psychiatric Care Setting when the person has refused to accept
the administration of such medications on a voluntary basis. Administration of such medications is
considered a significant procedure. Significant procedures can only be performed after the person
has been committed and only when there is good cause. A Medication Override Procedure must meet
the requirements of OAR 309-033-0640, Involuntary Administration of Significant Procedures to a
Committed Person with good cause. These procedures are used as a way to administer treatment to
an OHP Member who is incapable of providing informed consent and is in need of Treatment.
87. “Mental Health Information System” or “MHIS” means the information system of DHS that
includes the CPMS for community based services and the OP/RCS for inpatient and acute services.
It provides a statewide client registry and DHS Contractor registry for tracking service Utilization
and DHS Contractor Capacity.
88. “Mental Health Practitioner” means a person with current and appropriate licensure, certification,
or accreditation in a mental health profession, which includes but is not limited to: psychiatrists,
psychologists, registered psychiatric nurses, QMHAs, and QMHPs.
89. “Mental Health Services” means those clinical services provided to an OHP Member by a Mental
Health Practitioner.
90. “Multi-Family Treatment Group” means the planned Treatment of mental health needs identified
in the mental health Assessment which occurs in a group Setting of at least three children (none of
whom are siblings, step-siblings, or live in the same household) and their families. Groups are of
limited duration and designed for children and families dealing with similar issues.
91. “National Provider Identifier” or “NPI” means a federally directed Provider number mandated for
use on HIPAA covered transactions; individuals, Provider Organization and Subparts of Provider
Organizations that meet the definition of health care Provider (45 CFR 160.103) and who conduct
HIPAA covered transactions electronically are eligible to apply for an NPI; Medicare covered entities
are required to apply for an NPI.
92. “Notice of Action” means a written document issued to the OHP Member when a Service, benefit,
request for service authorization, or request for claim payment is denied. The Notice of Action
includes the following elements: (a) a statement of the Action, the effective date of such Action, and
the date the Notice of Action is mailed; (b) the reasons for the Action and the specific regulations that
support the Action; (c) an explanation of the right to file a Grievance with ABHA and to request an
Administrative Hearing with DHS, and the consequences of choices made; (d) a statement referring
the OHP Member to an enclosed informational notice of Grievance process form; (e) a statement
referring the OHP Member to an enclosed informational notice of Hearing rights form; and (f) the
name and telephone number of a person to contact for additional information.
93. “Notice of Intended Remedial Action” means a written document issued to COIHS when DHS
intends to take Remedial Action. The Notice of Intended Remedial Action includes the following
elements: (a) a statement of the intended Remedial Action, the effective date of such intended
Remedial Action, and the date the Notice of Intended Remedial Action is mailed; (b) the reasons for
the intended Remedial Action; (c) an explanation of COIHS’s right to request an administrative
review as described in the MHO Agreement; (d) an explanation that the intended Remedial Action
will be suspended when COIHS requests an administrative review before the effective date of the
intended Remedial Action and such request also includes a request to suspend the intended Remedial
Action until a decision is reached through the administrative review process; (e) an explanation that
Effective: January 1, 2011
Exhibit A Page 18 of 221
if the intended Remedial Action is suspended as described above in (d) and a decision is reached in
favor of DHS, the intended Remedial Action may be imposed retroactively to effective date stated in
the Notice of Intended Remedial Action; and (f) in cases where the Remedial Action includes
withholding of Capitation Payments because COIHS has failed to Provide Covered Services and/or
DHS has incurred costs in providing Covered Services, a list of OHP Members for whom Capitation
Payments will be withheld, the nature of the Covered Services denied by COIHS, and costs incurred
by DHS in providing Covered Services in accordance with this Agreement.
94. “Nursing Home” or “Nursing Facility” means an establishment with permanent facilities for the
comprehensive care of persons who require assistance with activities of daily living and 24-hour
nursing care. Nursing services exclude surgical procedures and include complex nursing tasks that
cannot be delegated to an unlicensed person. A Nursing Facility is licensed and operated pursuant to
Oregon Revised Statute 441.020(2).
95. “Oregon Health Plan” or “OHP” means the Medicaid and State Children’s Health Insurance
(SCHIP) Demonstration Project, which expands Medicaid and the SCHIP eligibility to eligible OHP
Clients. The OHP relies substantially upon prioritization of health services and managed care to
achieve the public policy objectives of access, cost containment, efficacy and cost effectiveness in the
allocation of health resources.
96. “OHP Client” means an individual found eligible by DHS to receive services under the OHP.
97. “OHP Member” means an OHP Client who is enrolled with COIHS under this Agreement.
98. “OHP Member Representative” means a person who can make OHP related decisions for OHP
Members who are not able to make such decisions themselves. An OHP Member Representative
may be, in the following order of priority, a person who is designated as the OHP Member’s health
care representative, a court-appointed guardian, a spouse, or other Family member as designated by
the OHP Member, the Individual Service Plan Team (for OHP Members with developmental
disabilities), parent or legal guardian of a minor below the age of consent, a DHS case manager or
other DHS designee. For OHP Members in the care or custody of CAF or OYA, the OHP Member
Representative is DHS or OYA. For OHP Members placed by DHS through a Voluntary Child
Placement Agreement (SCF form 499), the OHP Member shall be represented by his or her parent or
legal guardian.
99. “OHP Plus Benefit Package” means a benefit package with a comprehensive range of Services, as
described in OAR 410-120-1200, Medical Assistance Benefits, available to OHP Members who are
over the age of 65, the disabled, the TANF population, General Assistance recipients, and pregnant
women and children (under the age of 19) up to 185 percent of Federal Poverty Level (FPL).
100. “OHP Standard Benefit Package” means a benefit package that provides basic health care Services
as described in OAR 410-141-0050 and OAR 410-141-1200, Medical Assistance Benefits, for adults
who are not otherwise eligible for Medicaid (Families, Adults, Adults/Couples).
101. “Oregon Patient/Resident Care System” or “OP/RCS” means the DHS data system for persons
receiving services in the Oregon State Hospitals and selected community hospitals providing Acute
Inpatient Hospital Psychiatric services under contract with DHS.
102. “Oregon State Hospital” or “OSH” means the state-operated psychiatric hospital with campuses in
Salem and Portland, and the state-operated psychiatric hospital in Pendleton.
Effective: January 1, 2011
Exhibit A Page 19 of 221
103. “Other Inpatient Services” means services which are equivalent to Acute Inpatient Hospital
Psychiatric Care but which are provided in a non-hospital Setting.
104. “Outpatient Hospital Services” means Covered Services received in an outpatient hospital Setting
where the OHP Member has not been admitted to the facility as an inpatient, as defined in the DHS
Hospital Services Guide.
105. “Outreach” means services provided away from the service provider’s office, clinic or other place of
business in an effort to identify or serve OHP Members who might not otherwise obtain, keep or
benefit from usual appointments. Such services include, but are not limited to, community-based
visits with an OHP Member in an attempt to engage him or her in Medically Appropriate treatment,
and providing Medically Appropriate treatment in a Setting more natural or comfortable for the OHP
Member.
106. “Paraprofessional” means a worker who does not meet the definition of QMHA or QMHP but who
assists such associates and professionals.
107. “Parent Psychosocial Skills Development” means theoretically based interventions that focus on
developing and strengthening a parent's competencies in areas of functioning such as skills in
managing stress and reducing anger.
108. “Participating Provider” means an individual, facility, corporate entity, or other organization which
provides Covered Services under an agreement with ABHA and agrees to bill in accordance with
such agreement.
109. “PASSAGES Projects” means one type of Extended Care Project which consists of community-
based services for adults with severe and persistent mental illness who have been hospitalized for
over six months in an Oregon State Hospital or who have had difficulty maintaining stability in other
structured community Settings. Placements in these projects are approved by the ECMU.
110. “Peer Counseling” means a mental health service or support provided by trained persons with
characteristics similar to the Consumer such as persons in recovery from a major mental illness or
persons representing a generational cohort or persons with the same cultural background.
111. “Pended Encounters” means Encounters with critical errors that will process through the DHS’
MMIS. List post “must correct”, edits because of missing or erroneous data.
112. “Performance Improvement” or “PI” means improvement in the performance of the process of
health care and service delivery, rather than eliminating only low performing outliers. PI employs a
cyclical set of activities involving continuous planning, doing, checking and action (IOM 1990).
113. “Personal Care in Adult Foster Homes” means Medicaid-covered activities of daily living and
support services provided in a licensed Family home or other home for five or fewer persons who are
unable to live by themselves without supervision according to standards and procedures defined in
OAR 309-040-0000 through 309-040-0100.
114. “Post-Stabilization” means Covered Services related to an Emergency Situation that are provided
after an OHP Member is stabilized in order to maintain the stabilized condition, or to improve or
resolve the OHP Member’s condition.
Effective: January 1, 2011
Exhibit A Page 20 of 221
115. “Potential OHP Member” means an OHP Client who is subject to mandatory Enrollment or may
voluntarily elect to enroll in a managed care program, but is not yet enrolled with a specific PHP.
116. “Preadmission Screening and Resident Review” or “PASRR” means screening and Evaluation
services for residents of Nursing Facilities to determine their need for inpatient psychiatric
hospitalization according to federal standards and procedures defined in OAR 309-048-0050 through
309-048-0130.
117. “Prepaid Health Plan” or “PHP” means a managed health, dental, chemical dependency, or mental
health care organization that contracts with DHS on a case managed, prepaid, capitated basis under
the OHP. PHPs may be Dental Care Organizations (DCO), FCHPs, Chemical Dependency
Organizations (CDO), or MHO.
118. “Prevention” means services provided to stop, lessen or ameliorate the occurrence of mental
disorders.
119. “Primary Care Practitioner” or “PCP” means a general practice physician, Family physician,
general internist, pediatrician, or gynecologist who is responsible for providing and coordinating the
OHP Member's health care services. This person authorizes referrals to specialists and payment is
contingent upon these authorizations.
120. “Principal Diagnosis” means the reason that is chiefly responsible for the visit. See DSM, Use of
the Manual, page 3.
121. “Prioritized List of Health Services” means the listing of Condition/Treatment Pairs developed by
the HSC for the purpose of implementing the OHP. See OAR 410-141-0520, Prioritized List of
Health Services, for the listing of Condition/Treatment Pairs.
122. "Professional Liability Insurance" means coverage under the Federal Tort Claims Act (the
"FTCA") if ABHA is deemed covered under the FTCA, and to the extent the FTCA covers ABHA's
professional liability under this Agreement.
123. “Provide” means to furnish directly, or authorize and pay for the furnishing of, a Covered Service to
an OHP Member.
124. “Provider” means an organization, agency or individual licensed, certified or authorized by law to
render professional health services to OHP Members.
125. “Provider Panel” means those Participating Providers affiliated with the ABHA who are authorized
to Provide services to OHP Members.
126. “Provider Taxonomy Codes” means a standard administrative code set, as defined under HIPAA in
Federal regulations at 45 CFR 162, for identifying the provider type and area of specialization for all
health care providers.
127. “Psychiatric Day Treatment” means community-based day or residential treatment services for
children in a psychiatric treatment Setting which conforms to established state-approved standards.
128. “Psychiatric Rehabilitation” means the application of treatment for the purpose of restoring a
person to a former or desired state of overall functioning. See definition of Intensive Psychiatric
Rehabilitation.
Effective: January 1, 2011
Exhibit A Page 21 of 221
129. “Psychiatric Security Review Board” or “PSRB” means the Board authorized under ORS Chapter
161 which has jurisdiction over persons who are charged with a crime and found guilty except for
insanity.
130. “Psychiatric Vocational Project” means one type of Extended Care Project which includes two
community-based projects jointly funded by DHS. These two projects, Bridges in Washington
County and Laurel Hill in Eugene, Provide Intensive Psychiatric Rehabilitation Services with a
vocational emphasis. Placement in these projects is approved by the ECMU.
131. “Psychoeducational Program” means training conducted for the purpose of creating an awareness
of mental disorders and Treatment.
132. “Qualified Mental Health Associate” or “QMHA” means a person delivering services under the
direct supervision of a QMHP and meeting the following minimum qualifications as documented by
ABHA: a bachelor’s degree in a behavioral sciences field; or a combination of at least three years’
relevant work, education, training or experience; and has the competencies necessary to communicate
effectively; understand mental health Assessment, treatment and service terminology and to apply the
concepts; and Provide psychosocial Skills Development and to implement interventions prescribed on
a Treatment Plan within their scope of practice.
133. “Qualified Mental Health Professional” or “QMHP” means a LMP or any other person meeting
the following minimum qualifications as documented by ABHA: graduate degree in psychology;
bachelor’s degree in nursing and licensed by the State of Oregon; graduate degree in social work;
graduate degree in behavioral science field; graduate degree in recreational, art, or music therapy; or
bachelor’s degree in occupational therapy and licensed by the State of Oregon; and whose education
and experience demonstrates the competencies to identify precipitating events; gather histories of
mental and physical disabilities, alcohol and drug use, past mental health services and criminal justice
contacts; assess Family, social and work relationships; conduct a mental status examination;
document a multiaxial DSM Diagnosis; write and supervise a Treatment Plan; conduct a
Comprehensive Mental Health Assessment; and Provide Individual Therapy, Family Therapy, and/or
Group Therapy within the scope of their training.
134. “Quality Assessment” or “QA” means the measurement of both the technical and interpersonal
aspects of care (process) and the outcomes of that care. As such, it is the first step in Quality
Assurance and Performance Improvement. It does not move beyond problem detection and
measurement (IOM 1990).
135. “Quality Assurance” means a full cycle of activities for measuring Quality of Care and maintaining
it at acceptable levels.
136. “Quality Assessment/Performance Improvement Plan” or “QA/PI Plan” means a program that
includes the basic elements as described in 42 CRF 438.240.
137. “Quality of Care” means the degree to which services produce desired health outcomes and
satisfaction of Consumers, and are consistent with current best practices.
138. “Reasonable Accommodation” means consistent with the Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973, means a modification to policies, practices, or
procedures when the modification is necessary to avoid discrimination on the basis of disability
unless the service provider can demonstrate that making the modification would fundamentally alter
Effective: January 1, 2011
Exhibit A Page 22 of 221
the nature of the service, program or activity. Reasonable Accommodations may include, but are not
limited to, activities such as the following: (1) reading, or providing a tape of, material otherwise
provided in written format to a person with a visual impairment; (2) providing a service in a more
accessible location for a person with a mobility and other impairment; (3) providing assistance to a
person with a disability in completing applications and other paperwork necessary to receipt of
services; and (4) modifying a waiting area layout to accommodate a person in a wheelchair.
139. “Recoup” means to deduct or withhold (part of something due) for an equitable reason. Recoupment
occurs as a deduction on the next month's Capitation Payment and is reflected on the Remittance
Advice. Types of actions that can trigger a recoupment include mid-month OHP Member out of
Service Area moves, change of PHPs, and retroactive Disenrollment actions.
140. “Rehabilitative Services” means any Medically Appropriate remedial services for the maximum
reduction of a mental disability and attainment by the covered individual of his/her best possible
functional level.
141. “Reinsurance” means to insure by contracting to transfer in whole or in part a risk or contingent
liability already covered under an existing contract.
142. “Remedial Action” means an action taken by DHS when, in its sole judgment, it determines that
ABHA is out of compliance with this Agreement or its agreement with COIHS. A Remedial Action
includes one or more of the following actions: suspension of Enrollment of new OHP Members,
reduction of the number of OHP Members, or withholding of a portion of Capitation Payments. A
Remedial Action continues until such time as DHS determines that COIHS is in compliance with the
MHO Agreement and DHS has recovered all costs incurred in the provision of Covered Services
required by this Agreement.
143. “Rendering Provider ID” means an identification number, assigned by DMAP, used to represent
the OHP Participating Provider delivering Covered Services on behalf of the OHP.
144. “Rendering Provider Name” means an individual or organization who provides Covered Services
on behalf of the OHP. For billing purposes, within the OHP system, the Rendering Provider may or
may not be the billing provider, as defined in OAR 410-120-0000.
145. “Residential Service” means the organization of services in a home or facility including room,
board, care and other services provided to adults assessed to be in need of such services. Residential
Services include, but are not limited to, Residential Care Facilities, Residential Treatment Facilities,
Residential Treatment Homes, Crisis Respite Services and Secure Residential Treatment Facilities.
Residential Services do not include Supported Housing programs.
146. “Residential Treatment Facility” means a facility that is operated to provide supervision, care and
treatment on a 24-hour basis for six or more residents consistent with ORS 443.400 through ORS
443.455.
147. “Residential Treatment Home” means a home that is operated to Provide supervision, care and
treatment on a 24-hour basis for five or fewer residents consistent with ORS 443.400 through ORS
443.455.
148. “Restricted Reserve Fund” means a fund that is separate from ongoing operation accounts and is
limited for use to prevent insolvency. This fund is set up to meet unexpected cash needs and to cover
debts when an organization discontinues its role as a DHS contractor or subcontractor. This fund
Effective: January 1, 2011
Exhibit A Page 23 of 221
may not be used to meet expected ongoing obligations such as withholds, incentive payments and the
like.
149. “Secure Adolescent Inpatient Program” or “SAIP” means Services Provided in an appropriately
certified facility designated by DHS as LTPC, for adolescents, age 14 through 17, determined by the
AMH Child and Adolescent Mental Health Specialist to be appropriate for LTPC.
150. “Secure Children's Inpatient Program” or “SCIP” means Services Provided in an appropriately
certified facility designated by DHS as LTPC, for children, age 13 and under, determined by the
AMH Child and Adolescent Mental Health Specialist to be appropriate for LTPC.
151. “Service” means the care, treatment, Service Coordination or other assistance provided to an OHP
Member.
152. “Service Area” means the geographic area in which ABHA is responsible for delivering Covered
Services under this Agreement.
153. “Services Coordination” means Services provided to OHP Members who require access to and/or
receive services from one or more Allied Agencies or program components according to the
Treatment Plan. Services provided may include establishing pre-commitment service linkages;
advocating for treatment needs; and providing assistance in obtaining entitlements based on mental or
emotional disability.
154. “Setting” means the locations at which Covered Services are provided. Settings include such
locations as mental health offices, an individual's home or school or other identified locations.
155. “Skills Training” means a program of rehabilitation as prescribed in the Treatment Plan which is
designed to improve social functioning in areas important to maintaining or re-establishing residency
in community, such as money management, nutrition, food preparation, community awareness, and
community mobility. Skills Training can be provided on an individual basis or in a group Setting.
156. “Special Health Care Needs” means individuals who either 1) have functional disabilities, or 2) live
with health or social conditions that place them at risk of developing functional disabilities (for
example, serious chronic illnesses, or certain environmental risk factors such as homelessness or
family problems that lead to the need for placement in foster care.
157. “Specialized Medication Adjustment” means medication adjustments that because of the
complexity or danger, require a level of expertise beyond that of the usual LMP for that setting or
client.
158. “Stabilization and Transition Services” or “STS” means services Provided in an appropriately
certified facility designated by DHS as LTPC for children and adolescents under age 17 determined
by the AMH Child and Adolescent Mental Health Specialist to be appropriate for LTPC, but who can
be served in an enhanced short term treatment Setting.
159. “Stakeholders” means persons, organizations and groups with an interest in how Covered Services
are delivered under this Agreement. Stakeholders may include, but are not limited to, OHP
Members, Consumers, Families, Allied Agencies, child psychiatrists, child advocates, advocacy
groups, and other groups.
Effective: January 1, 2011
Exhibit A Page 24 of 221
160. “State Hospital” means State-operated psychiatric hospitals including OSH in Salem and Portland,
and Eastern Oregon Psychiatric Center in Pendleton.
161. “Stop Loss Coverage” means protection against catastrophic and unexpected expenses related to
Covered Services. The method of protection may include the purchase of stop loss insurance,
Reinsurance, self insurance or any other alternative determined acceptable by COIHS.
162. “Subacute Psychiatric Care” means care characterized by the commitment of treatment resources
toward the resolution or amelioration of a significant, but not serious, mental health problem over a
relatively short period of time.
163. “Supported Housing” means provision of mental health rehabilitation services in the home or other
community setting for the purpose of assisting a person to live independently. Such services
typically include skill development in money management, nutrition, and community living;
assistance with health issues and taking prescribed medications; and provision of supportive
counseling.
164. “Tertiary Treatment” means complementary medical, psychological, or rehabilitative procedures
designed to eliminate, relieve or minimize mental or emotional disorders.
165. “Therapeutic Group Home” means a home providing planned Treatment to a child in a small
residential Setting. Treatment includes theoretically based individual and group home Skills
Development and Medication Management, Individual Therapy and Consultations as needed, to
remediate significant impairments in the child's functioning that are the result of a principal mental or
emotional disorder diagnosed on Axis I of the DSM multi-axial Diagnosis.
166. “Third Party Resources and Personal Injury Lien” mean any payments, benefits, or other
resources available from a Third Party, including but not limited to:
a. Private health insurance or group health plan;
b. Employment-related health insurance;
c. Medical support from absent parents;
d. Workers’ compensation;
e. Medicare;
f. Automobile liability insurance; and
g. Other federal programs such as Armed Forces Retirees and Dependent Act (CHAMPVA),
Armed Forces Active Duty and Dependents Military Medical Benefits Act (CHAMPUS), and
Medicare Parts A and B, unless excluded by statute as for example:
(1) Services provided to OHP Members pursuant to 42 CFR 136.61 Indian Health Service
(IHS) is the payer of last resort and is not considered a Third Party Resource; or
(2) Services provided to OHP Members at a tribal facility operated under a “638”
agreement pursuant to the Memorandum of Agreement between IHS and CMS is a
payer of last resort and is not considered a Third Party Resource.
Effective: January 1, 2011
Exhibit A Page 25 of 221
h. Claims, judgments, settlements or compromises in relation to personal injuries where the
Covered Services paid by ABHA constitute assistance, as these terms are defined in ORS
416.510.
i. Another state's Title XIX, Title XXI, or state-funded Medical Assistance Program.
j. Personal estates.
167. “365 Project” means one type of Extended Care Program which is a community-based alternative to
Oregon State Hospital services developed on an individualized basis for persons with state
hospitalization episodes of one year or longer. These are extended care projects that Provide
intensive services and supports to enable approved adults to live in community rather than
institutional Settings. Persons must be approved for placement in these projects by the ECMU.
168. “Traditional Service” means a Medically Appropriate mental health service defined in the State of
Oregon, OHP Service Categories for Per Capita Costs, October 2001 through September 2002.
Traditional Services are those services that have historically been used to treat mental disorders and
include services for which Medicaid FFS billing categories exist. For OHP Members under 21 years
of age Traditional Services include the following: interpreter services; Assessment and Evaluation;
Consultation; Clinical Services Coordination; Case Management; Medication Management;
Individual Therapy, Family Therapy and Group Therapy; Multi-Family Treatment Group; Individual
Skills Development and Group Skills Development; Intensive Treatment, Structure and Support; 24-
hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care. For OHP
Members 21 years of age and older Traditional Services include the following: interpreter services;
Assessment and Evaluation; Consultation; Case Management; Medication Management; Individual
Therapy, Family Therapy and Group Therapy; Daily Structure and Support; Individual and Group
Skills Training; 24-hour Urgent and Emergency Response; Acute Inpatient Hospital Psychiatric Care;
and Covered Services provided in a variety of residential Settings.
169. “Treatment” means a planned, Medically Appropriate, individualized program of interactive
medical, psychological, or rehabilitative procedures, experiences, and/or activities designed to
rehabilitate, relieve or minimize mental or emotional disorders identified through a mental health
Assessment.
170. “Treatment Foster Care” means a program of rehabilitation as prescribed in the Treatment Plan and
provided in the child's foster home. Skill development activities are delivered on an individualized
basis and are designed to promote skill development in areas identified in the Treatment Plan. The
service requires the use of Treatment Foster Care in coordination with other mental health
interventions to reduce symptoms associated with the child's mental or emotional disorder and to
provide a structured, therapeutic environment. The service is intended to reduce the need for future
services, increase the child's potential to remain in the community, restore the child's best possible
functional level, and to allow the child to be maintained in a least restrictive setting.
171. “Treatment Parameters” means the set of all variables that may affect the treatment of a client.
Included in this set are providers, medical treatments, psychological treatments, and social
interventions.
172. “Treatment Plan” means a written individualized comprehensive plan based on a completed mental
health Assessment documenting the OHP Member's treatment goals, measurable objectives, the array
of services planned, and the criteria for goal achievement.
Effective: January 1, 2011
Exhibit A Page 26 of 221
173. “Twenty-four (24) Hour Urgent and Emergency Services” means Services available 24 hours per
day for persons experiencing an acute mental or emotional disturbance potentially endangering their
health or safety or that of others, (or with respect to a pregnant woman, the health of the woman or
her unborn child), but not necessarily creating a sufficient cause for Civil Commitment as set forth in
OAR 309-033-0200 through 309-033-0340.
174. “Urban Indian Organization” means a clinic designated as an Urban Indian Health Program
(UIHP) under Title V of the Indian Health Care Improvement Act, Public Law 94-437, enrolled with
DHS as a FQHC.
175. “Urgent Care” means care which is medically necessary within 48 hours to prevent a serious
deterioration in an OHP Member's mental health.
176. "Urgent Situation” means a situation requiring attention within 48 hours to prevent a serious
deterioration in an OHP Member's mental health.
177. “Usual and Customary Charges” means an amount which reflects the provider’s charge per unit of
service established in accordance with OAR 410-120-0000 or other applicable state and federal laws,
rules and regulations, not in excess of the provider’s usual and customary charge to the general
public.
178. “Usual and Customary Treatment” means the application of Treatment used to prevent the need
for LTPC. Treatments include the following: (1) medical screens and Assessments used to rule out a
medical condition or identify a medical condition that may be impacting a mental disorder; (2)
appropriate use of psychotropic medications in therapeutic dosages and adjustments to such dosages
to minimize side effects; (3) other cognitive and behavioral therapeutic interventions; and (4) review
of options for discharge to nonhospital levels of care. For members who will be admitted to the
OSH-GTS, Usual and Customary Treatment includes coordination of the stabilization of acute
medical problems.
179. “Utilization” means the amount and/or pattern of Covered Services used by an OHP Member,
measured, for example, in dollars, units of service, or staff time.
180. “Utilization Guidelines” means guidelines for the amount of Covered Services expected to be used
by an OHP Member with a specific mental disorder over time.
181. “Utilization Management” means the process used to regulate the provision of services in relation
to the overall Capacity of the organization and the needs of Consumers.
182. “Valid Claim” means an invoice received by the ABHA for payment of Covered Services rendered
to an OHP Member which can be processed without obtaining additional information from the
provider of the service or from a third party; and has been received within the time limitations
prescribed in Oregon Administrative Rule 410-141-0420; Billing and Payment under the Oregon
Health Plan and is synonymous with the federal definition of a "clean claim" as defined in 42 CFR
447.45(b).
Effective: January 1, 2011
Exhibit B Page 27 of 221
Exhibit B – Statement of Work
ABHA agrees to perform its responsibilities consistent with the responsibilities entailed in its
agreement with AMH in effect prior to this Agreement, in accordance with the terms, conditions,
and specifications provided in this Agreement, including the Statement of Work. In addition,
ABHA agrees to perform delegated responsibilities related to the provision of chemical
dependency services consistent with the contractual obligations of COIHS, as referenced in the
“FCHP Contract”.
Effective: January 1, 2011
Exhibit B – Part I Page 28 of 221
Exhibit B – Statement of Work – Part I - Benefits
1. Benefit Package
ABHA shall Provide OHP Plus Benefit Package and OHP Standard Benefit Package of Covered
Services to OHP Members consistent with OAR 410-141-0120, Oregon Health Plan Prepaid Health Plan
Provision of Health Care Services; OAR 410-141-0520, Prioritized List of Health Services; and OAR
410-141-0480, Oregon Health Plan Benefit Package of Covered Services. Covered Services shall be
sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the
Services are provided. ABHA shall ensure that the Services offered are in an amount, duration, and
scope that is no less than that furnished to OHP Clients under FFS. ABHA may cover, for OHP
Members, Services that are in addition to those covered under the State plan.
a. OHP Plus Benefit Package
A benefit package with a comprehensive range of services available to OHP Members who are
over the age of 65, the disabled, the TANF population, General Assistance recipients, pregnant
women and children under the age of 19. ABHA, in partnership with COIHS, shall notify OHP
Members eligible for the OHP Plus Benefit Package of their responsibility to pay a co-payment
for some services as specified in OAR 410-120-1230.
b. OHP Standard Benefit Package
A benefit package that provides basic health care Services for adults who are not otherwise
eligible for Medicaid (Families, Adults/Couples). This benefit package has premiums
requirements.
c. Flexible Services
When delivering a Flexible Service (as opposed to using a Flexible Service Approach) and the
Provider rendering a Flexible Service is not licensed or certified by a state board or licensing
agency, or employs personnel to provide the service who do not meet the definition for Qualified
Mental Health Associate (QMHA) or Qualified Mental Health Professional (QMHP) as
described in Exhibit A, Definitions, Provider must meet criteria described in Exhibit B, Part II,
Section 3, Credentialing Process, Subsection a.(1)(b).
d. Provision of Covered Services
(1) ABHA shall provide reimbursement for Covered Services obtained outside its Service
Area when such Covered Services are not available within its Service Area.
(2) Notwithstanding 410-141-0500, (1) (b), ABHA shall provide Covered Services as
Medically Appropriate to those CAF children residing inside the Service Area and those
children whose placement by CAF for Behavioral Rehabilitative Services (BRS) is
outside the Service Area.
(3) ABHA shall Provide all Covered Services to OHP Members but may require, except in
an emergency, that OHP Members obtain such Covered Services from ABHA or
Providers affiliated with ABHA. ABHA shall Adjudicate Valid Claims within 45
calendar days of receipt. ABHA shall ensure that neither COIHS nor the OHP Member
Effective: January 1, 2011
Exhibit B – Part I Page 29 of 221
receiving Services are held liable for any costs or charges related to Covered Services
rendered to an OHP Member whether in an emergency or otherwise.
(4) ABHA’s obligation to pay for Emergency Services that are received from non-
Participating Providers is limited to Covered Services that are needed immediately and
the time required to reach ABHA or a Participating Provider (or alternatives authorized
by ABHA) would have meant substantial risk to the OHP Member’s health or safety or
the health or safety of another.
(a) Covered Services following the provision of Emergency Services are considered
to be Emergency Services as long as transfer of the OHP Member to ABHA or a
Participating Provider or the designated alternative is precluded because of risk to
the OHP Member’s health or safety or that of another because transfer would be
unreasonable, given the distance involved in the transfer and the nature of the
mental health condition.
(b) ABHA is responsible for arranging for transportation and transfer of the OHP
Member to ABHA’s care when it can be done without harmful consequences.
(5) ABHA shall pay for Covered Services, subject to the protection of the prudent layperson
requirements in Exhibit B-Part I, Section 1, Subsection d(4)(a) needed to assess an
Emergency Situation. If ABHA has a reasonable basis to believe that Covered Services
claimed to be Emergency Services were not in fact Emergency Services, ABHA may
deny payment for such services. Such Services shall not be considered Covered Services.
In such circumstances, ABHA shall, within 45 calendar days of receipt of a claim for
payment, notify:
(a) The Provider of such Services of the decision to deny payment, the basis for that
decision, and the Provider’s right to contest that decision.
(b) The OHP Member of the decision to deny payment as described in Exhibit N,
Grievance System.
(6) ABHA may not prohibit or otherwise restrict a mental Health Care Professional (acting
within the lawful scope of practice) from advising or advocating on behalf of an OHP
Member for:
(a) the OHP Member’s mental health care status, medical care or treatment options,
including any alternative treatment that may be self-administered, regardless of
whether ABHA provides benefits for the particular type of care or treatment;
(b) any information the OHP Member needs in order to decide among all the relevant
treatment options;
(c) the risks, benefits, and consequences of treatment or non-treatment;
(d) the OHP Member’s rights to participate in decisions regarding his or her mental
health care as cited in 42 CFR 438.102 (a)(1)(iv), including the right to refuse
treatment, and to express preferences about future treatment decisions.
Effective: January 1, 2011
Exhibit B – Part I Page 30 of 221
(7) ABHA shall provide for a second opinion from a qualified mental Health Care
Professional within the Provider Panel, or arrange for the ability of the OHP Member to
obtain one outside the Provider Panel, at no cost to the OHP Member.
(8) As per 42 CFR 438.102, ABHA is not required to provide coverage or reimburse a
counseling or referral Service if ABHA objects to the Service on moral or religious
grounds. ABHA shall notify COIHS if there are any Services not provided by the ABHA
due to moral or religious reasons or if there is no limitation on Services. ABHA shall
provide this notification at least 15 days before the start of a new Agreement or
implementation of a newly adopted policy. If ABHA has not changed its policy
regarding provision of Services since the beginning of the preceding contract year, it shall
so notify COIHS by submission of Schedule 8. ABHA shall provide this information to
OHP Members within 90 days of any changes to its policy. ABHA shall also make
available this same information to Potential OHP Members before and during
Enrollment.
e. Mental Health Services which are Not Covered Services
ABHA shall assist its OHP Members in gaining access to certain mental health Services that are
not Covered Services and that are provided under separate contract with COIHS or DHS.
Services that are not Covered Services include, but are not limited to, the following:
(1) Medical Transportation pursuant to rules (OAR 410-136-0020 et. seq.) promulgated by
DHS and published in its Medical Transportation Services Guide;
(2) Medication;
(3) Therapeutic Foster Care reimbursed under HCPC Code S5145 for OHP Members under
21 years of age;
(4) Therapeutic Group Home reimbursed for OHP Members under 21 years of age;
(5) Behavioral Rehabilitative Services that are financed through Medicaid and regulated by
DHS Services to Children and Families and OYA;
(6) Investigation of OHP Members for Civil Commitment;
(7) LTPC as defined in Exhibit B, Part II, Section 1, Subsection c (10), for OHP Members 21
years of age and older;
(8) PASRR for OHP Members seeking admission to a Nursing Home;
(9) LTPC for OHP Members age 17 and under;
(a) Secure Children's Inpatient program (SCIP)
(b) Secure Adolescent Inpatient Program (SAIP)
(c) Stabilization and Transition Services (STS)
Effective: January 1, 2011
Exhibit B – Part I Page 31 of 221
(10) Extended care Services for OHP Members 18 years of age and older including Extended
Care Management, Enhanced Care Services provided in SPD Program licensed facilities,
“365” Projects, Psychiatric Vocational Projects, PASSAGES Projects, and other Services
developed as less restrictive alternatives to LTPC at an Oregon State Hospital;
(11) Personal Care in Adult Foster Homes for OHP Members 21 years of age and older;
(12) Other Residential Services for OHP Members 21 years of age and older provided in
Residential Care Facilities, Residential Treatment Facilities and Residential Treatment
Homes;
(13) Services provided to persons while in the custody of a correctional facility or jail;
(14) Abuse investigations and protective Services as described in OAR 309-040-0200 through
309-040-0290, Abuse Reporting and Protective Services in Community Programs and
Community Facilities, and ORS 430.735 through ORS 430.765, Abuse Reporting for the
Mentally Ill; and
(15) Personal Care Services as described in OAR 411-034-0000 through 411-034-0090 and
OAR 309-040-0300 through 309-040-0330.
f. Client Notices
Each time a Service or benefit will be terminated, suspended or reduced, or a request for Service
authorization or request for claim payment is denied, ABHA shall issue a Notice of Action, in
accordance with requirements established in Exhibit N, Section 3 (Grievance System). ABHA
shall make available in all clinics, Participating Provider offices, and other Service locations
frequented by OHP Members, information concerning Client Notices, Grievances, Appeals, and
Administrative Hearings.
g. Practice Guidelines
ABHA shall adopt practice guidelines, specified in 42 CFR 438.236 (b), (c) and (d), that are
based on valid and reliable clinical evidence or a consensus of mental health professionals.
These practice guidelines must consider the needs of OHP Members, be adopted in Consultation
with ABHA’s Participating Providers, and be reviewed and updated periodically as appropriate.
ABHA shall disseminate the practice guidelines to all affected Providers and, upon request, to
OHP Member or OHP Member Representative. Decisions for Utilization Management, OHP
Member education, coverage of Services, or other areas to which the guidelines apply, should be
consistent with the adopted practice guidelines.
h. Utilization Management
(1) ABHA shall have written Utilization Management policies, procedures and criteria for
Covered Services. These Utilization Management procedures shall be consistent with
appropriate Utilization control requirements of 42 CFR Part 456.
(2) ABHA shall provide compensation to subcontractors that conduct Utilization
Management activities and is not structured so as to provide incentives for the
subcontractors to deny, limit or discontinue Medically Appropriate services to any OHP
Member.
Effective: January 1, 2011
Exhibit B – Part I Page 32 of 221
(3) ABHA may adopt Treatment Parameters or Utilization Guidelines which result in
limitations being placed on Covered Services; however, ABHA shall assure that
Medically Appropriate level of Covered Services is provided based on the needs of the
OHP Member regardless of limits specified in any such Treatment Parameters or
Utilization Guidelines. ABHA may not arbitrarily deny or reduce the amount, duration,
or scope of a Covered Service solely because of the Diagnosis, type of illness, or
condition, subject to the Prioritized List of Health Services.
(4) If ABHA adopts Treatment Parameters or Utilization Guidelines, ABHA shall provide
copies of such existing Treatment Parameters and Utilization Guidelines to COIHS as of
the effective date of this Agreement, within 30 calendar days of change or adoption, and
within 15 calendar days of COIHS request.
(5) ABHA shall disseminate Treatment Parameters or Utilization Guidelines to all affected
Providers and, upon request, to OHP Member or OHP Member Representative.
(6) If ABHA adopts Treatment Parameters or Utilization Guidelines, ABHA shall establish
an appeal process that allows for an independent clinical review of the decision by one or
more QMHPs who were not involved in the original Utilization Management decision.
ABHA may use its appeal process for resolving Utilization Management appeals.
(a) The appeal process of ABHA shall afford those persons requesting Covered
Services an expeditious method of reviewing Utilization Management decisions.
(b) ABHA shall have written policies and procedures for its Utilization Management
appeal process, notify organizations, agencies and Health Care Professionals
requesting Covered Services of such process, and, upon request, provide a copy of
written Utilization Management appeal policies and procedures.
(c) ABHA shall coordinate all appeals with the COIHS Grievance and Appeals
department. It is understood that COIHS will process all appeals for Behavioral
Health Services consistent with Exhibit N.
i. Authorization for Services
(1) ABHA and subcontractor, if so delegated shall have written policies and procedures for
processing requests for initial and continuing authorization of services from an OHP
Member or Provider.
These procedures shall include mechanisms to ensure consistent application of review
criteria for authorization decisions; which would include the consultation with the
requesting Provider when appropriate.
(2) Decisions made by a Health Care Professional with the appropriate clinical expertise in
treating the OHP Member’s mental health condition, must be included in any
determination to deny a service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested. Notification of any adverse
decision made must occur in writing and provided to the OHP Member and Provider.
Notification to the Provider need not be in writing.
Effective: January 1, 2011
Exhibit B – Part I Page 33 of 221
(3) For standard Service authorization requests, ABHA and subcontractor, if so delegated,
shall provide notice as expeditiously as the OHP Member’s mental health condition
requires, not to exceed fourteen (14) calendar days following receipt of the request for
Service, with a possible extension of 14 additional calendar days if the OHP Member or
Provider requests extension, or if the ABHA justifies a need for additional information
and how the extension is in the OHP Member’s interest. If ABHA extends the time
frame, ABHA shall give the OHP Member and Provider a written notice of the reason for
the decision to extend the timeframe and inform the OHP Member of the right to file a
Grievance if he or she disagrees with that decision. When a decision is not reached
regarding a Service authorization request within the timeframes specified above, ABHA
shall issue a Notice of Action to the Provider and OHP Member, or OHP Member
Representative, consistent with Exhibit N, Grievance System.
(4) If an OHP Member or Provider requests, or ABHA determines, that following the
standard timeframes could seriously jeopardize the OHP Member’s life or health or
ability to attain, maintain, or regain maximum function, ABHA shall make an expedited
Service authorization decision and provide Notice as expeditiously as the OHP Member’s
mental health condition requires and no later than 3 working days after receipt of the
request for Service. ABHA may extend the 3 working days time period by up to 14
calendar days if the OHP Member requests an extension, or if ABHA justifies a need for
additional information and how the extension is in the OHP Member’s interest.
2. Revision of Covered Services
Consistent with state law, Covered Services may be expanded, limited or otherwise changed by the
HSC, by a vote of the people, or by the Legislative Assembly. ABHA shall Provide Covered Services
consistent with the expansion or limitation, subject to ABHA’s right to terminate this Agreement as
provided for in Exhibit D, Section 9, Termination and Section 19, Amendments. ABHA will be held
responsible for maintaining Covered Services consistent with state law and HSC or DHS publications.
3. (Reserved)
4. Chemical Dependency
ABHA shall provide Chemical Dependency Services to eligible OHP Members, which include
Outpatient treatment services, Opiate Substitution Services, and Intensive Outpatient treatment services.
For purposes of this Contract, AMH rules and criteria applicable to Outpatient treatment services are
located in OAR 415-051-0000, and the AMH rules and criteria applicable to synthetic opiate treatment
services located in OAR 415-020-0000. For technical assistance related to this section of this
Agreement, the AMH contact shall be the OHP Alcohol and Drug Specialist, Addictions and Mental
Health Medicaid Policy Unit.
a. ABHA shall make decisions about access to Chemical Dependency Services, continued stay,
discharges, and referrals based upon AMH approved criteria, which are deemed to be Medically
Appropriate. ABHA shall ensure that employees or Subcontractors who evaluate OHP Members
for access to and length of stay in Chemical Dependency Services have the training and
background in Chemical Dependency Services and working knowledge of ASAM PPC-2R.
ABHA shall participate with AMH in a review of AMH provided data about the impact of these
criteria on service quality, cost, outcome, and access.
Effective: January 1, 2011
Exhibit B – Part I Page 34 of 221
b. ABHA shall consider each eligible OHP Member’s needs and, to the extent appropriate and
possible, provide specialized Chemical Dependency Services designed specifically for the
following groups as set forth in AMH administrative rules: a) adolescents, taking into
consideration adolescent development, b) women, and women’s specific issues, c) ethnic and
racial diversity and environments that are culturally relevant, d) intravenous drug users, e) people
involved with the criminal justice system and f) individuals with co-occurring disorders.
c. Consistent with Exhibit B, Part II, Section 5, Services Coordination for Non-Capitated Services,
ABHA shall coordinate referral and follow-up of OHP Members to Non-Capitated Services such
as residential treatment services, and community detoxification. ABHA’s employees or
Subcontractors providing Chemical Dependency Services shall provide to OHP Member, to the
extent of available community resources and as clinically indicated, information and referral to
community services which may include, but are not limited to: child care; elder care; housing;
transportation; employment; vocational training; educational services; mental health services;
financial; and legal services.
d. ABHA shall authorize and pay for at least Outpatient Chemical Dependency Services to eligible
OHP Members who meet AMH criteria for residential treatment services, community
detoxification, or opiate substitution maintenance, when residential treatment services are not
immediately available.
e. ABHA shall require employees or Subcontractors providing Chemical Dependency Services to
provide AMH, within 30 days of admission or discharge, with all information required by
AMH’s most current publication “Client Process Monitoring System.”
f. ABHA shall utilize AMH approved chemical dependency screening tools for prevention, early
detection, brief intervention and referral to chemical dependency treatment. ABHA may submit
alternative screening tools to AMH for review and possible approval. For a list of the AMH
approved screening tools contact the OHP Alcohol and Drug Specialist.
g. ABHA shall make a good faith effort to screen all eligible OHP Members and provide
prevention, early detection, brief intervention and referral to chemical dependency treatment who
are in any of the following circumstances: a) at an initial contact or routine physical exam, b) at
an initial prenatal exam, c) when the OHP Member shows evidence of chemical dependency or
abuse (as noted in the AMH approved screening tools), or d) when the OHP Member over-
utilizes Capitated Services.
h. ABHA shall ensure that individuals or programs have a letter of approval or license from AMH
for the Chemical Dependency Services they provide and meet all other applicable requirements
of this Contract, except that providers under The Drug Addiction Treatment Act of 2000, Title
42 Section 3502 Waiver may treat and prescribe Buprenorphine for opioid addiction in any
appropriate practice setting in which they are otherwise credentialed to practice and in which
such treatment would be Medically Appropriate.
i. ABHA, in partnership with COIHS, shall inform all eligible OHP Members that chemical
dependency outpatient, intensive outpatient and medication assisted treatment services, including
opiate substitution treatment, are included in the Plus and Standard Benefit package consistent
with OAR 410-141-0300.
j. ABHA shall provide covered Chemical Dependency Services for any eligible OHP Member
who meets admission criteria for outpatient, intensive outpatient and medication assisted
Effective: January 1, 2011
Exhibit B – Part I Page 35 of 221
treatment including opiate substitution treatment, regardless of prior alcohol/other drug treatment
or education.
k. ABHA shall comply with the following access requirements: eligible OHP Members shall be
seen the same day for emergency chemical dependency treatment care. Eligible OHP Members,
including pregnant women, shall be seen within 48 hours for urgent chemical dependency
treatment care. Eligible OHP Members, including intravenous drug users, shall be seen within 10
days or the community standard for routine chemical dependency treatment care.
l. In addition to any other confidentiality requirements described in this Contract, ABHA shall
follow the federal (42 CFR Part 2) and State (ORS 179.505, 430.397, 430.399) confidentiality
laws and regulations governing the identity and medical/client records of OHP Members who
receive Chemical Dependency Services.
m. ABHA shall identify and assure OHP Members have access to specialized programs in each
Service Area in the following categories: drug court referrals, Children, Adults and Families
(CAF) referrals, Job Opportunities and Basic Skills (JOBS) referrals, and referrals for persons
with co-occurring disorders.
n. ABHA shall provide OHP Members with alcohol, tobacco, and other drug abuse
prevention/education that reduces substance abuse risk to DMAP Members. ABHA’s prevention
program shall meet or model national quality assurance standards. ABHA should have
mechanisms to monitor the use of its preventive programs and assess their effectiveness on OHP
Members.
5. Accessibility and Continuity of Care
a. ABHA shall meet, and require Providers to meet, OHP standards for timely access to care and
Services, taking into account the urgency of need for Services. ABHA shall comply with OAR
410-141-0220, Oregon Health Plan Prepaid Health Plan Accessibility and OAR 410-141-0160,
Oregon Health Plan Prepaid Health Plan Continuity of Care. ABHA shall ensure that Providers
do not discriminate between OHP Members and non-OHP persons as it relates to benefits and
services to which they are both entitled and shall ensure that Providers offer hours of operation to
OHP Members that are no less than those offered to non-OHP Members.
b. In addition to access and Continuity of Care standards specified in the rules cited in Subsection
a, of this section, ABHA shall establish standards for access to Covered Services and Continuity
of Care which, at a minimum, include the following:
(1) For Urgent Services and Emergency Services, ABHA shall assure that OHP Members
receive an initial face-to-face or telephone screening within 15 minutes of contact to
determine the nature and urgency of the situation.
(2) For Emergency Services, ABHA shall assure that OHP Members receive timely Covered
Services within time frames identified by the urgent and emergency response screening
or within 24 hours of contact, whichever is shorter.
(3) For Urgent Services, ABHA shall assure that OHP Members receive timely Covered
Services within time frames identified by the urgent and emergency response screening
or within 48 hours of request, whichever is shorter.
Effective: January 1, 2011
Exhibit B – Part I Page 36 of 221
(4) For non-Urgent Services and non-Emergency Services, ABHA shall assure that OHP
Members wait no more than two calendar weeks to be seen for an Intake Assessment
following a request for Covered Services.
(5) For post-hospital services, ABHA shall assure that OHP Members receive a Covered
Service within one calendar week following discharge from Acute Inpatient Psychiatric
Hospital Care or that such OHP Members receive follow-up Covered Services within a
Medically Appropriate period of time.
(6) For missed appointments, ABHA shall follow-up and reschedule appointments or
Provide Outreach Services as Medically Appropriate or needed to prevent serious
deterioration of the OHP Member’s mental health condition.
(7) For routine travel time from the OHP Member residence to the Participating Provider,
ABHA shall assure that OHP Members spend no more time traveling than the
Community Standard.
(8) For OHP Members who are placed in substitute care by DHS, ABHA shall Provide a
comprehensive mental health Assessment consistent with access and Continuity of Care
standards specified in Subsection a, of this section. ABHA shall provide this Assessment
no later than 60 days following the date of placement.
c. ABHA shall establish mechanisms to ensure that Providers comply with the timely access
requirements, monitor regularly to determine compliance, and take Corrective Action if there is a
failure to comply.
d. ABHA shall have a method of responding to telephone calls from non-English speaking OHP
Members and shall make available to these OHP Members, interpreters capable of effectively
receiving, interpreting and translating routine and clinical information.
e. ABHA shall have a method of responding to telephone calls from hearing impaired OHP
Members and shall make available to these OHP Members, TDD Service and sign language or
oral interpreters capable of effectively receiving, interpreting and translating routine and clinical
information.
f. ABHA, in partnership with COIHS, shall notify OHP Members that oral interpretation is
available for prevalent non-English language, written information is available in each prevalent
non-English language and how to access those services.
g. ABHA shall make Reasonable Accommodations to administrative practices and Service
approaches for Service access and Continuity of Care for OHP Members with disability.
h. ABHA shall allow OHP Members to request an Assessment and Evaluation without obtaining a
referral from another Provider.
i. ABHA shall Provide each OHP Member with an opportunity to select an appropriate Mental
Health Practitioner and Service site.
j. ABHA shall ensure that each Native American or Alaska Native enrolled with ABHA shall be
allowed to choose an Indian Health Care Provider as the OHP Member’s primary mental health
care Provider if:
Effective: January 1, 2011
Exhibit B – Part I Page 37 of 221
(1) An Indian Health Care Provider is participating as a primary mental health care Provider
within the ABHA’s network; and
(2) The Native American or Alaska Native OHP Member is otherwise eligible to receive
services from such Indian Health Care Provider; and
(3) The Indian Health Care Provider has the capacity to Provide primary mental health care
services to such OHP Members.
k. ABHA shall Provide for the identified Covered Service needs of an OHP Member during
transfer from one practitioner or hospital to another regardless of whether the practitioners or
hospitals are Participating Providers. ABHA shall develop a written plan for Continuity of Care
to avoid a worsening of the OHP Member’s mental disorder when transitioning the OHP
Member. ABHA shall document that such plan is acceptable to the OHP Member and/or OHP
Member Representative or that the OHP Member and/or OHP Member Representative has been
advised of the Grievance and Administrative Hearings processes.
l. ABHA shall not deny Covered Services to, or request Disenrollment of, an OHP Member based
on disruptive or abusive behavior resulting from symptoms of a mental disorder or from another
disability. ABHA shall develop an appropriate Treatment Plan with the OHP Member and the
Family or advocate of the OHP Member to manage such behavior.
m. ABHA shall take into consideration the Service needs of OHP Members with Special Health
Care Needs when establishing its Provider network.
n. ABHA shall implement mechanisms to assess each OHP Member with Special Health Care
needs in order to identify any ongoing special conditions that require a course of mental health
treatment or care management. The Assessment mechanisms must use appropriate Mental Health
Practitioners.
(1) For OHP Members with Special Health Care Needs determined to need a course of
treatment or regular care monitoring, the Treatment Plan must be developed by the
Mental Health Practitioner with OHP Member participation and in Consultation with any
specialists caring for the OHP Member; approved by ABHA in a timely manner, if
approval is required; and developed in accordance with any applicable DHS Quality
Assessment and Performance Improvement and Utilization Review standards.
(2) Based on the Assessment, ABHA shall assist OHP Members with Special Health Care
Needs in gaining direct access to Medically Appropriate care from mental health
specialists for treatment of the OHP Member’s condition and identified needs.
(3) ABHA shall implement procedures to share with OHP Member’s primary health care
provider and FCHP the results of its identification and Assessment of any OHP Member
with Special Health Care Needs so that those activities need not be duplicated. Such
coordination and sharing of information shall be conducted within Federal and State
laws, rules, and regulations governing confidentiality.
Effective: January 1, 2011
Exhibit B – Part II Page 38 of 221
Exhibit B –Statement of Work – Part II – Providers and Delivery System
1. Delivery System Configuration
a. Delivery System Capacity
(1) As specified in 42 CFR 438.206, ABHA shall maintain and monitor a Provider Panel
that is supported with written agreements, and that has sufficient Capacity and
expertise to Provide adequate, timely and Medically Appropriate access to Covered
Services to OHP Members across the age span from child to older adult. In
establishing and maintaining the Provider Panel, ABHA shall consider the following:
(a) The anticipated Medicaid Enrollment;
(b) An appropriate range of preventive and specialty services for the population
enrolled or expected to be enrolled in the Service Area;
(c) The expected Utilization of Services, taking into consideration the
characteristics and mental health care needs of OHP Members;
(d) The number and types (in terms of training, experience, and specialization) of
Providers required to Provide Services under this Agreement;
(e) The number of Providers who are not accepting new OHP Members; and
(f) The geographic location of Providers and OHP Members, considering distance,
travel time, the means of transportation ordinarily used by OHP Members,
taking into account whether the location provides physical access for OHP
Members with Disabilities.
(2) ABHA shall allow each OHP Member to choose a Provider within ABHA’s Provider
Panel to the extent possible and appropriate.
(3) ABHA shall provide OHP Members with access, as Medically Appropriate, to
psychiatrists, other licensed medical professionals, or mental health professionals.
(4) ABHA shall demonstrate that the number of Indian Health Care Providers that are
Participating Providers are sufficient to ensure timely access to Covered Services
within the scope of Covered Services specified under this Agreement, for those Native
American or Alaska Natives enrolled with the ABHA who are eligible to receive
services from such providers, or demonstrate in the ABHA’s Service Area(s) that there
are no or few Indian Health Care Providers.
(5) ABHA shall identify training needs of its Provider Panel and address such needs to
improve the ability of the Provider Panel to deliver Covered Services to OHP
Members.
(6) If ABHA is unable to Provide necessary Covered Services which are Medically
Appropriate to a particular OHP Member within its Provider Panel, ABHA shall
adequately and timely cover these services out of network for the OHP Member, for as
long as ABHA is unable to Provide them. Out of network providers must coordinate
Effective: January 1, 2011
Exhibit B – Part II Page 39 of 221
with ABHA with respect to payment. ABHA shall ensure that cost to OHP Member is
no greater than it would be if the Services were provided within the Provider Panel.
(7) ABHA shall participate in DHS efforts to promote the delivery of Services in a
Culturally Competent manner to OHP Members, including those with limited English
proficiency and diverse cultural and ethnic backgrounds.
(8) ABHA shall coordinate its Service delivery system planning effort with organized
planning efforts carried out by the LMHA of its Service Area.
b. Components of the Delivery System
(1) Services Coordination
(a) ABHA shall have written policies and procedures for the provision of Services
Coordination for those OHP Members with unique needs or requiring Services
from more than one Allied Agency.
(b) ABHA shall manage all Covered Services for its OHP Members with unique
needs or requiring Services from more than one Allied Agency. Such policies
and procedures shall be specific to these agencies.
(2) Preventive and Early Intervention Services
(a) ABHA shall establish and conduct preventive mental health and
Psychoeducational Programs to decrease the incidence, prevalence, and
residual effects of mental disorders in selected areas of the OHP Member
population.
(b) ABHA shall have mechanisms to determine the presence and prevalence of
mental disorders in its OHP Membership.
(3) Rehabilitative Treatment Services
(a) ABHA shall establish and make available Services for OHP Members who
have non-urgent or non-emergency needs for Covered Services. These
Services shall include Rehabilitative Covered Services.
(b) ABHA shall establish written policies and procedures that ensure Covered
Services, which are Rehabilitative, are provided within Medically Appropriate
time frames.
(4) 24 Hour Urgent and Emergency Response System
(a) ABHA shall furnish covered mental health Emergency Services that are
needed immediately, or appear to be needed immediately by a prudent
layperson, because of a sudden mental health condition. ABHA is responsible
for coverage and payment for mental health Emergency Services and Post-
Stabilization Services which are Medically Appropriate, until the emergency is
stabilized, including those of non-participating Mental Health Practitioners or
licensed facilities. ABHA may not deny payment for covered mental health
Effective: January 1, 2011
Exhibit B – Part II Page 40 of 221
Emergency Services or Post-Stabilization Services obtained under either of the
following circumstances:
(i) an OHP Member had an Emergency Situation, including cases in which
a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate
medical attention to result in placing the health of the individual in
serious jeopardy, serious impairment or dysfunction of any bodily part
or organ; or
(ii) when a representative of the ABHA, or its Providers, instructs the OHP
Member to seek Emergency Services.
(b) ABHA may not limit what constitutes an Emergency Situation on the basis of
lists of diagnoses or symptoms.
(c) ABHA may not refuse to cover Emergency Services based on Provider’s
failure to notify ABHA, of the OHP Member’s screening and treatment, within
10 calendar days of the OHP Member’s presentation for Emergency Services.
(d) An OHP Member who presents for Emergency Services may not be held liable
for payment of subsequent Services needed to diagnose the specific condition
or stabilize the OHP Member.
(e) ABHA must limit charges to OHP Members for Post-Stabilization care
Services to an amount no greater than what ABHA would charge the OHP
Member if he or she had obtained the Services through ABHA.
(f) The attending physician, or the Provider actually treating the OHP Member, is
responsible for determining when the OHP Member is sufficiently stabilized
for transfer or discharge, and that determination is binding on ABHA.
(g) ABHA is financially responsible for Post-Stabilization Services under the
following circumstances:
(i) Post-Stabilization Services that have been pre-approved by ABHA, or
subcontractor;
(ii) Post-Stabilization Services that have not been pre-approved but
provided to maintain the OHP Member’s stabilized condition within 1
hour of a request to the ABHA, or subcontractor for pre-approval of
further Post-Stabilization Services;
(iii) Post-Stabilization Services that have not been pre-approved but were
provided to maintain, improve, or resolve the OHP Member’s stabilized
condition if Provider does not receive a response to a request for pre-
approval within 1 hour; ABHA, or subcontractor cannot be contacted;
or an agreement cannot be reached between subcontractor and treating
Provider and ABHA is not available for Consultation. In this situation,
the treating Provider may continue Services to the OHP Member until
ABHA can be reached.
Effective: January 1, 2011
Exhibit B – Part II Page 41 of 221
(h) ABHA’s financial responsibility ends for Post-Stabilization Services that have
not been pre-approved when:
(i) ABHA’s Participating Provider with privileges at the treating hospital
assumes responsibility for the OHP Member’s care;
(ii) ABHA’s Participating Provider assumes responsibility for OHP
Member’s care through transfer;
(iii) Subcontractor and treating Provider reach an agreement concerning the
OHP Member’s care; or
(iv) The OHP Member is discharged.
(i) ABHA shall establish, consistent with OAR 410-141-0140, Oregon Health
Plan Prepaid Health Plan Emergency and Urgent Care Medical Services, an
Urgent and Emergency Response System that operates 24 hours per day, 7
days per week.
(j) ABHA shall have, and adhere to, written policies and procedures for an
Emergency Response System that provides an immediate, initial and/or limited
duration response consisting of: a telephone or face to face screening to
determine the nature of the situation and the person’s immediate need for
Covered Services; capacity to conduct the elements of a mental health
Assessment that are needed to determine the interventions necessary to begin
stabilizing the crisis situation; development of a written initial Services plan at
the conclusion of the mental health Assessment; provision of Covered Services
and/or Outreach needed to address the Urgent or Emergency Situation; and
linkage with the public sector crisis services, such as pre-commitment.
(5) Involuntary Psychiatric Care
(a) ABHA shall make a reasonable effort to Provide Covered Services on a
voluntary basis and consistent with current Declaration for Mental Health
Treatment in lieu of involuntary treatment.
(b) ABHA shall have written policies and procedures describing the appropriate
use of Emergency Psychiatric Holds and alternatives to Involuntary Psychiatric
Care when a less restrictive voluntary Service will not meet the Medically
Appropriate needs of the OHP Member and the behavior of the OHP Member
meets legal standards for the use of an Emergency Psychiatric Hold.
(c) ABHA shall only use psychiatric inpatient facilities and non-inpatient facilities
certified by DHS under OAR 309-033-0200 through 309-033-0340, Standards
for the Approval of Facilities that Provide Care, Custody and Treatment to
Committed Persons or to Persons in Custody or on Diversion, to Provide
Emergency Psychiatric Holds.
(d) ABHA shall comply with ORS Chapter 426, OAR 309-033-0200 through 309-
033-0340, and OAR 309-033-0400 through 309-033-0440 for involuntary
Effective: January 1, 2011
Exhibit B – Part II Page 42 of 221
Civil Commitment of those OHP Members who are civilly committed under
ORS 426.130.
(e) ABHA shall administer medication to OHP Members held or civilly
committed under ORS Chapter 426, regardless of Setting, only as permitted by
applicable statute and administrative rule. ABHA shall not transfer civilly
committed OHP Members to a State Hospital for the sole purpose of obtaining
authorization to administer medication on an involuntary basis.
(6) Adult Mental Health
ABHA shall provide oversight, care coordination and transition and planning
management of OHP Members within the targeted population of AMHI to ensure
community-based care is provided in a way that OHP Members are served in a most
natural environment possible and that the use of institutional care is minimized. The
intensity, frequency and blend of these services are based on the mental health needs
of the OHP Member. ABHA shall involve COIHS in all discussions related to the
transition of AMHI capitation or financial risk to the MHO contractor(s) to the extent
those discussions impact the service area represented by this contract.
Target population: The targeted population is that subset of OHP Members who,
because of a mental illness are:
(a) Currently residing at a State Hospital;
(b) Currently residing in a licensed community-based setting;
(c) Under a Civil Commitment; or
(d) Would deteriorate to meeting one of the above criteria without treatment and
community supports.
(7) Acute Inpatient Hospital Psychiatric Care
(a) ABHA shall maintain agreements with local and regional hospitals for the
provision of emergency and non-emergency hospitalization for OHP Members
with mental disorders that require Acute Inpatient Hospital Psychiatric Care.
Hospitals selected must comply with standards as described in Exhibit B, Part
II, Section 4, Credentialing Process, Subsection a.(2) and (3).
(b) In support of ORS 441.094 (5), managed care organization hospital contracting
requirements, ABHA shall, submit data to COIHS for further submission to
DHS, as specified in Exhibit K, Provider Capacity Assurance Report (PCAR),
Attachment 1-Form 1. This report is due no later than March 15 of each
contract year.
(c) ABHA shall cover the cost of Acute Inpatient Hospital Psychiatric Care for
OHP Members who do not meet the criteria for LTPC.
(d) ABHA may request of ECMU the transfer of an OHP Member from an Acute
Inpatient Hospital Psychiatric Care Setting to a highly secure psychiatric
Effective: January 1, 2011
Exhibit B – Part II Page 43 of 221
Setting when ABHA believes that the extremely assaultive behavior of the
OHP Member warrants such a Setting. If the OHP Member does not consent
to such a transfer, ABHA may, subject to applicable law, initiate an
Emergency Psychiatric Hold and a pre-commitment investigation. The care
rendered to an OHP Member transferred to a highly secure psychiatric Setting
at ABHA’s request is a Covered Service and the cost thereof shall be borne by
ABHA unless and until the OHP Member is determined appropriate for LTPC
in accordance with the process described in this Agreement. If the OHP
Member is admitted to a State Hospital, ABHA shall pay the usual and
customary rates for this level of Service until such time as the OHP Member is
discharged or determined appropriate for LTPC.
(e) ABHA shall coordinate admissions to and discharges from Acute Inpatient
Hospital Psychiatric Care for OHP Members in the care and custody of DHS
Children, Adults, and Family Services or OYA with such OHP Member’s
DHS Services to Children and Families or OYA case manager. For an OHP
Member placed by DHS Children, Adults, and Family Services through a
Voluntary Child Placement Agreement (SCF form 499), coordination shall
also occur with such OHP Member’s parent or legal guardian.
(8) Integrated Service Array (ISA) for Children and Adolescents
(a) The ISA is a range of service components for children and adolescents,
through and including age 17. These services target the population with severe
mental or emotional disorders whose needs have not been adequately
addressed in traditional Settings. ABHA shall ensure that the ISA will be
recovery focused, family guided, and time limited based on Medically
Appropriate criteria.
(b) ABHA shall develop and implement a system for the ISA that provides cost
effective, comprehensive and individualized care to children and their families.
(i) ABHA shall have a system that promotes collaboration, within laws
governing confidentiality, between mental health, child welfare,
juvenile justice, education, families, and other community partners in
the treatment of children with serious emotional, mental health and
behavioral challenges.
(ii) ABHA shall assure access to referral and screening at multiple entry
points.
(iii) ABHAs shall Provide Services that are family-driven, strengths-based,
are culturally sensitive, and that enhance and promote quality,
community-based Service delivery.
(c) ABHA shall have policies and procedures in place to assess all OHP Members
who are children and adolescents suspected of having significant mental or
emotional disorders.
(i) The Child and Adolescent Service Intensity Instrument (CASII) will be
used as the statewide tool to assist in the determination for ISA services
Effective: January 1, 2011
Exhibit B – Part II Page 44 of 221
for children age 6 and older. For children 5 and younger, the statewide
tool will be the Early Childhood Service Intensity Instrument (ECSII).
(ii) ABHA will prioritize children with the most serious mental health
needs for the ISA who have a mental health Diagnosis that is on or
above the funded line of the OHP Prioritized List of Health Services.
This mental health Diagnosis must be the focus of the ISA and the
Treatment Plan. In addition to considering the level of service intensity
need indicated by the CASII or ECSII score, ABHA shall take into
consideration factors including, but not limited to:
(A) exceeding usual and customary services in an outpatient
Setting;
(B) multiple agency involvement;
(C) history of one or more out-of-home placements;
(D) significant risk of out-of-home placement;
(E) frequent or imminent admission to acute inpatient psychiatric
hospitalizations or other intensive treatment services;
(F) caregiver stress;
(G) school disruption due to mental health symptomatology;
(H) elevating or significant risk of harm to self or others; or
(I) for children birth to 5:
• history of abuse or neglect;
• conditions interfering with parenting, such as poverty,
substance abuse, mental health problems, and domestic
violence, and
• significant relationship disturbance between parent(s)
and child.
(iii) The ISA determination process shall be clearly communicated to
Family members, guardians, and community partners, and shall
encourage ISA referrals from multiple sources, including families,
Allied Agencies, schools, juvenile justice, the faith community and
health care providers.
(iv) ABHA shall make decisions regarding ISA determinations and referrals
to Services within three (3) working days consistent with ABHA’s
policies and procedures required in Exhibit B, Part II, Section 1,
Subsection b, Paragraph (8)
Effective: January 1, 2011
Exhibit B – Part II Page 45 of 221
(v) OHP Members meeting the determination process outlined in Exhibit
B, Part II, Section 1, Subsection b, Paragraph (8) (c) (ii) for intensive
treatment services shall have access to care coordination, shall have
available a child and family team planning process and access to the
ISA.
(vi) ABHA shall continue to Provide Services consistent with access
standards identified in Exhibit B, Part I, Section 4, Subsection a and
Subsection 2, Paragraph (1) through (4) for the time period between
level of service intensity determination review and approval and
implementation of the service plan.
(vii) ABHA shall submit written policies and procedures for CASII and
ECSII administration and ISA determination processes to COIHS
within 15 calendar days of the effective date of this Agreement.
COIHS will review the policies and procedures and notify ABHA of its
determination of the review and approval within 45 days of receipt.
(viii) ABHA shall assure that admissions to psychiatric residential treatment
services are consistent with the admission and certification
requirements of 42 CFR 456.481.
(d) ABHA shall assure that Service Coordination will be provided by a person or
persons who have a strong child and adolescent mental health background,
extensive knowledge of the children’s system of care, and experience working
with families.
(i) Community Care Coordination shall provide guidance and Case
Management services in the planning, facilitating, and coordination of
the child’s Service Coordination plan.
(ii) A child and family team shall assist in the development of the Service
Coordination plan. The team may include the child, if appropriate,
Family members, child serving agencies involved with the child,
school, and other community supports identified by the Family.
(iii) The child and family team will support and help facilitate access to a
combination of Services, informal and formal supports, and other
community resources.
(e) ABHA shall develop and implement a Community Care Coordination
Committee that is a community level planning and decision making body to
provide practice-level Consultation, identify needed community services and
supports, and provide a forum for problem solving to families, ISA providers,
child serving agencies, and child and family teams. The Community Care
Coordination Committee shall have representation of the local system of care
that includes Consumer and Family members, child serving providers, child
and family advocates, and other local Stakeholders representative of the local
system of care.
Effective: January 1, 2011
Exhibit B – Part II Page 46 of 221
(f) ABHA shall develop and implement a regional or local children’s mental
health system advisory council. The advisory council will advise ABHA and
provide oversight of the local or regional mental health policies and programs
for the ISA, as well as ensure continuous QA/PI.
(i) The advisory council shall have representation from child welfare,
juvenile justice, education, developmental disabilities, physical health
plan, ISA providers, and other local or regional community partners
representative of the local system of care, culturally diverse populations
of mental health Consumers and their Family members.
(ii) Representation by Consumers, Family members and child and family
advocates on this advisory council shall be a minimum of 51% of total
membership, with half of the representation consisting of OHP
Members who are adolescent Consumers and family members of OHP
Members who are child and adolescent Consumers.
(g) ABHA shall collaborate with COIHS to work closely with DHS to ensure
continuous Enrollment for children and adolescents determined as meeting the
criteria for the ISA who are placed in treatment facilities outside ABHA’s
Service Area, as defined in Part IV of this Agreement. ABHA shall
collaborate with COIHS in order to notify DHS when an OHP Member is
admitted to an out of area program, as well as when the OHP Member is
scheduled for discharge from the program.
(h) ABHA shall develop a process to assure that funding intended and allocated
for children's mental health is used for that purpose.
(i) Performance targets for the percentage of expenditures on services to
children and adolescents shall be equal to the percentage of revenues
based on child and adolescent OHP Members.
(ii) OHP Members meeting criteria for the ISA, as described in Exhibit B,
Part II, Section 1, Subsection b, Paragraph (8) (c), shall be served by a
provider certified to provide intensive community based treatment
services under OAR 309-032-1500 to 309-032-1565.
(i) ABHA shall have contractual relationships or memorandums of understanding
with Providers certified to provide intensive treatment services that
demonstrate adequate and sufficient Capacity to Provide the ISA.
(j) ABHA shall have policies and procedures in place to assure timely
reimbursement to Providers participating in the ISA.
Whenever ABHA reimburses a non-contract provider of Psychiatric Day
Treatment Services or Psychiatric Residential Treatment Services for services
identical to those purchased by DHS through direct contracts, the
reimbursement shall be no less than the amount paid by DHS for the same
services.
Effective: January 1, 2011
Exhibit B – Part II Page 47 of 221
(k) ABHA shall have written policies and procedures describing the admission and
discharge criteria for a child or adolescent requiring the ISA level of care.
Process shall include the active participation of the Family, Allied Agencies,
and other persons involved in the child’s care.
(l) ABHA shall be required to submit additional reports and information as
identified by COIHS or DHS for the purposes of QA/PI activities of the ISA.
ABHA shall work with COIHS and DHS to identify specific outcomes and
performance measures that will be tracked and reported on a quarterly basis.
(i) DHS will conduct an annual survey of Family members/caregivers of
child and adolescent OHP Members receiving Covered Services and
may provide aggregate results and raw data received from COIHS’
members to COIHS which will be shared with ABHA.
(ii) ABHA shall be required to submit additional reports and information
derived from this aggregate data as identified by COIHS or DHS for
the purposes of QA/PI activities of the ISA.
(iii) ABHA shall collect and analyze CASII and ECSII data for QA/PI
activities. ABHA shall submit to COIHS, within 45 days of the end of
each calendar quarter, a report consistent with Schedule 4, Level of
Service Intensity Determination Data.
(iv) ABHA and COIHS shall collaborate and assist DHS in the collection
and reporting of data for use in an ISA Progress Review, as indicators
of outcome and performance measure. Data shall include the following
domains:
(A) School;
(B) Home, life, and Family;
(C) Client functioning; and
(D) Critical incidents.
(m) In addition to the Utilization Management requirements stated in Exhibit B,
Part I, Section 1, Subsection h, ABHA shall assure that admissions to
psychiatric residential treatment programs are consistent with the admission
and certification requirements of 42 CFR 456.481 and 441.150 through
441.156.
c. Integration and Coordination
ABHA shall ensure that in the process of coordinating care, the OHP Member's privacy is
protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164
subparts A and E, to the extent that they are applicable, and consistent with other State law or
Federal regulations governing privacy and confidentiality of mental health records.
Effective: January 1, 2011
Exhibit B – Part II Page 48 of 221
(1) Mental Health Services Which Are Not Covered Services
ABHA shall coordinate Services for each OHP Member who requires Services from
agencies providing mental health Services that are not Covered Services. These
Services include, but are not limited to, those listed in Exhibit B, Part I, Section 1,
Subsection e, Mental Health Services Which Are Not Covered Services.
(a) ABHA shall assist OHP Members who are children and adolescents age 17 and
under in gaining access to Psychiatric Long Term Care when this level of care
is Medically Appropriate.
(i) ABHA shall work closely with COIHS and/or DHS staff to ensure
continuous Enrollment for OHP Members entering into LTPC outside
of ABHA's Service Area as defined in Part IV of this Agreement.
(ii) To ensure that treatment is being provided in the least restrictive and
most appropriate Setting, ABHA shall, at minimum, consult and
communicate with LTPC programs for admission and discharge
planning, and collaborate with the LTPC program regarding ongoing
treatment decisions.
(iii) ABHA shall coordinate, consult, and communicate, within the laws
governing confidentiality, with community providers and other Allied
Agencies, schools, Family members or guardians regarding treatment
for children and adolescents in LTPC.
(2) Local Mental Health Authority (LMHA)/Community Mental Health Program (CMHP)
ABHA shall establish working relationships with the LMHA and CMHP operating in
the Service Area for the purposes of maintaining a comprehensive and coordinated
crisis response and mental health Service delivery system for OHP Member access to
mental health Services, including Civil Commitment and protective Services/Abuse
investigations processes.
(3) Community Emergency Service Agencies
ABHA shall coordinate, consult, communicate with, and provide technical assistance
to Community Emergency Service Agencies to promote appropriate responses to, and
appropriate Services for, OHP Members experiencing a mental health crisis.
(4) Allied Agencies
ABHA shall have a mechanism for multi-disciplinary team Service planning and
Services Coordination for OHP Members requiring Services from more than one
publicly funded agency or Service Provider. This mechanism shall help avoid Service
duplication and promote access to a range and intensity of Service options that Provide
individualized, Medically Appropriate care in the least restrictive Treatment Setting
(clinic, home, school, community based care Settings licensed by Allied Agencies).
(a) ABHA shall collaborate with COIHS and work with DHS local and/or regional
agencies to develop specific methods for meeting federal requirements for a
Effective: January 1, 2011
Exhibit B – Part II Page 49 of 221
mental health Assessment for children and adolescents within 60 days of
placement in substitute care.
(5) Physical Health Care Providers
(a) ABHA shall consult and communicate with the OHP Member’s physical
health care Provider as Medically Appropriate and within laws governing
confidentiality as specified in OAR 410-141-0180, Oregon Health Plan
Prepaid Health Plan Recordkeeping.
(b) ABHA shall consult with and provide technical assistance to physical health
care Providers in the Service Area to help in the early identification of mental
disorders so that intervention and Prevention strategies can begin as soon as
possible.
(c) Develop and implement methods of coordinating with FCHPs for the
appropriate coordination of Services delivered to OHP Members.
(6) Chemical Dependency Providers
ABHA shall coordinate with Chemical Dependency Providers as Medically
Appropriate and within laws governing confidentiality and shall provide technical
assistance for the identification and referral of OHP Members with dual diagnoses.
ABHA shall work with FCHPs and Chemical Dependency Providers certified by DHS
to develop the Capacity to Provide appropriate Services to dually diagnosed OHP
Members so the needs of such persons can be better met.
(7) Co-location/Integration of Primary Care and Covered Mental Health Services
(a) ABHA shall demonstrate the availability of covered services within the context
of a primary care setting, including, but not limited to, FQHCs and RHCs.
(b) If an FQHC or RHC has an arrangement or contract with ABHA, it is
responsible to follow all appropriate and legal rules and prior authorization
requirements. See OAR 410 Division 141 of OHP Program Rules and OAR
410-147-0060 Prior Authorization, as well as 42 USC 1396b(m)(2)(A)(ix) and
BBA 4712(b)(2).
(8) AMHI MHO ENCC Services
ABHA shall provide MHO ENCC services, to those OHP Members identified as
blind, disabled or who have complex medical needs, as specified in OAR 410-141-
0000 (a) through (e).
(9) Integration Activities
(a) ABHA shall develop, implement and participate in activities supportive of a
continuum of care that integrates mental health, addiction and physical health
interventions in ways that are seamless and whole to the OHP Member.
Integration activities may span a continuum ranging from communication to
Effective: January 1, 2011
Exhibit B – Part II Page 50 of 221
coordination to co-management to co-location to the fully integrated, person-
centered health care home.
(b) ABHA shall demonstrate involvement in integration activities such as, but not
limited to:
(i) Facilitation of communication and coordination between physical and
behavioral health care providers;
(ii) Enhanced communication and coordination between ABHA and
FCHPs, DCOs, physical health providers and chemical dependency
providers;
(iii) Implementation of integrated Prevention, early intervention and
wellness activities;
(iv) Development of infrastructure support for sharing information,
coordinating care and monitoring results;
(v) Use of screening tools treatment standards and guidelines that support
integration;
(vi) Support of a shared culture of integration across prepaid health plans
and service delivery systems; and
(vii) Implementation of a system of care approach, incorporating models
such as the Four Quadrant Clinical Integration Model of the National
Council for Community Behavioral Healthcare.
(10) Medicare Payers and Providers
(a) Pursuant to OAR 410-141-0120, ABHA shall coordinate with Medicare payers
and Providers as Medically Appropriate to coordinate the care and benefits of
OHP Members who are eligible for both Medicaid and Medicare.
(b) Pursuant to OAR 410-141 0420, ABHA shall be responsible for Medicare
deductibles, coinsurance and co-payments up to Medicare’s or ABHA’s
allowable for Covered Services its Medicare eligible OHP Members receive
from a Medicare Provider, who is either a Participating Provider, or a Non-
Participating Provider, if authorized by ABHA or ABHA’s representatives, or
for Emergency Services or Urgent Care Services.
(11) OHP Members in Extended Care Settings
ABHA shall coordinate with the ECMU and extended care Service Providers to
integrate Services for OHP Members in Extended Care Programs. ECMU shall
determine, after collaborating with ABHA and the Extended Care Program, when an
OHP Member is ready for discharge from the Extended Care Program.
(12) Long Term Psychiatric Care (LTPC)
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Exhibit B – Part II Page 51 of 221
(a) If ABHA believes an OHP Member is appropriate for LTPC, ABHA shall
request a LTPC determination from the applicable DHS program. DHS staff
will render a determination within three working days of receiving a completed
request if the OHP Member is 18 or more years of age or within seven working
days of receiving a completed request if the OHP Member is age 17 and under.
(i) For OHP Members age 18 to age 64 with no significant nursing care
needs due to an Axis III disorder of an enduring nature, the ECMU as
described in Schedule 2.1, Procedure for LTPC Determinations for
OHP Members Age 18-64;
(ii) For OHP Members age 17 and under, the AMH Child and Adolescent
Community Mental Health Specialist as described in Schedule 2.2,
Procedure for LTPC Determinations for OHP Members age 17 and
under; and
(iii) For OHP Members age 65 and over or age 18 to age 64 with significant
nursing care needs due to an Axis III disorder of an enduring nature,
the OSH-GTS, Outreach and Consultation Service (OCS) Team as
described in Schedule 2.3, Procedure for Long Term Psychiatric Care
Determinations for Persons Requiring Geropsychiatric Treatment.
(b) An OHP Member is appropriate for LTPC when the OHP Member needs either
Intensive Psychiatric Rehabilitation or other Tertiary Treatment in a State
Hospital or Extended Care Program, or Extended and Specialized Medication
Adjustment in a secure or otherwise highly supervised environment; and the
OHP Member has received all Usual and Customary Treatment, including, if
Medically Appropriate, establishment of a Medication Management Program
and use of a Medication Override Procedure.
(c) COIHS will cover the cost of LTPC of OHP Members determined appropriate
for such care beginning on the effective date specified below in this Exhibit B,
Part II, Section 1, Subsection c, Paragraph (10) (c) and ending on the date the
OHP Member is discharged from such setting
If an OHP Member is ultimately determined appropriate for LTPC, the
effective date of such determination shall be either:
(i) Within three (3) working days of the date ECMU receives a completed
Request for LTPC Determination for Persons Age 18 to 64 form, or
(ii) No more than seven (7) working days following the date the AMH
Child and Adolescent Mental Health Specialist receives a completed
request for LTPC Determination for Persons Age 17 and under form; or
(iii) The date the OSH-GTS OCS Team receives a completed Request for
LTPC Determination for Persons Requiring OSH-GTS; or
(iv) In cases where COIHS and ABHA mutually agree on a date other than
these dates, the date mutually agreed upon.
Effective: January 1, 2011
Exhibit B – Part II Page 52 of 221
(v) In cases where the Clinical Reviewer determines a date other than a
date described above in this Exhibit B, Part II, Section 1, Subsection c,
Paragraph (10) (c) (i) through (10) (c) (iii), the date determined by the
Clinical Reviewer.
In the event there is a disagreement between ABHA and COIHS about whether
an OHP Member is appropriate for LTPC, ABHA may request, , within two
(2) working days of receiving notice of the LTPC determination, review by an
independent Clinical Reviewer. The determination of the Clinical Reviewer
shall be deemed the determination of COIHS for purposes of this Agreement.
If the Clinical Reviewer ultimately determines that the OHP Member is
appropriate for LTPC, the effective date of such determination shall be the date
specified above in this Exhibit B, Part II, Section 1, Subsection c, Paragraph
(12) (c). The cost of the clinical review shall be divided equally between
ABHA and COIHS.
(d) ABHA shall:
(i) For OHP Members age 18 to 64, work with the ECMU, or OCS Team
in managing admissions to and discharges from LTPC for OHP
Members who require such care at OSH or Eastern Oregon Psychiatric
Center.
(ii) For OHP Members, age 17 and under, work with the AMH Child and
Adolescent Mental Health Specialist in managing admissions and
discharges to LTPC (SCIP, SAIP, STS programs).
(iii) For the OHP Member and, the parent or guardian of the OHP Member,
work to assure timely discharge from LTPC to an appropriate
community placement.
(iv) For the OSH-GTS Interdisciplinary Treatment Team assigned to the
OHP Member, work to manage discharges from Long Term
Geropsychiatric Care.
(e) ABHA shall authorize and reimburse Case Management services that are
sufficient in amount, duration or scope to reasonably be expected to achieve
the purpose for which the services are provided to OHP Members receiving
care through community-based Long Term Psychiatric Care, as authorized by
the ECMU.
(f) ABHA shall assure that any involuntary treatment provided under this
Agreement is provided in accordance with administrative rule and statute, and
shall coordinate with the CMHP Director in assuring that all statutory
requirements are met. ABHA shall also work with the CMHP Director in
assigning a civilly committed OHP Member to any placement and participate
in circuit court hearings related to planned placements, if applicable.
(13) Consumer Involvement and Advocacy
Effective: January 1, 2011
Exhibit B – Part II Page 53 of 221
(a) ABHA shall involve Consumers, families, Consumer advocates, and advocacy
groups in planning, developing, implementing, operating and evaluating
Services.
(b) ABHAs’ advisory bodies or policy-making bodies shall, as referenced in ORS
430.075, have representation from culturally diverse populations of mental
health Consumers and their Family members. Representation on these
advisory bodies shall be a minimum of 25% of total membership and shall
consist of representatives which include the following constituent groups:
adolescent Consumers, adult Consumers, older adult Consumers, Family
members of child and adolescent Consumers and Family members of adult and
older adult Consumers.
(c) ABHA shall inform OHP Members, at least once per year, of the OHP
Member’s abilities to participate in activities of ABHA.
2. Quality Assessment/Performance Improvement (QA/PI) Requirements
a. QA/PI Program
a. ABHA shall assist COIHS in the development of an ongoing QA/PI program for the
services it furnishes to its OHP Members in accordance with 42 CFR 438.240, which
requires the following:
(a) Conduct a minimum of two (2) performance improvement projects (PIP) that
are designed to achieve, through ongoing measurements and intervention,
significant improvement, sustained over time, in clinical and non-clinical areas
that are expected to have favorable effect on health outcomes and OHP
Member satisfaction. ABHA shall perform a mental health/physical health
collaborative PIP with a Fully Capitated Health Plan (FCHP)/Physician’s Care
Organization (PCO) also serving OHP Members in COIHS’ Service Area. As
an alternative to a collaborative PIP, ABHA may propose another PIP to
COIHS which must be reviewed by and have prior approval by DHS and
COIHS. The ongoing program of PIPs shall include the following:
(i) Measurement of performance using objective quality indicators;
(ii) Implementation of system interventions to achieve improvement;
(iii) Evaluation of the effectiveness of the interventions;
(iv) Planning and initiation of activities for increasing or sustaining
improvement; and
(v) Completion in a reasonable time period as to generally allow
information on the success of PIP(s) in the aggregate to produce new
information on quality every year;
(b) Submit performance measurement data:
(i) Using standard measures required by DHS;
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Exhibit B – Part II Page 54 of 221
(ii) As specified by DHS, and that enables COIHS to measure ABHA’s
performance; or
(iii) A combination of (i) or (ii) above;
(c) Have in effect mechanisms to detect both underutilization and over utilization
of services; and
(d) Have in effect mechanisms to assess the quality and appropriateness of care
furnished to OHP Members.
b. ABHA shall establish a QA/PI Committee that shall meet at least every two (2)
months. The committee shall retain authority and accountability to the executive(s)
for the quality assessment and performance improvement of care.
The committee membership shall include, but is not limited to, the QA/PI
Coordinator, other health professionals who are representative of the scope of
the services delivered, and 25% Consumers stakeholder participation, as
described in Exhibit B, Part II, Section c.(13) “Consumer Involvement and
Advocacy” of this Agreement.
c. ABHA, with assistance from COIHS, shall develop and submit QA/PI Workplan
within 35 days of the effective date of this Agreement to COIHS. The written QA/PI
Program Workplan is subject to approval by DHS and COIHS and shall contain the
following:
(a) A brief description of the PIPs;
(b) Performance measurement, as applicable;
(c) Underutilization and overutilization of services;
(d) Ongoing and regular monitoring of provider compliance of access standards;
and
(e) Assessment of the quality and appropriateness of care furnished to its OHP
Members.
COIHS shall notify ABHA of DHS’ determination of approval upon receipt of
notification from DHS.
d. ABHA, with assistance from COIHS, shall submit a QA/PI Program Work Plan
Report with the status and results of:
(a) Each PIP;
(b) Performance measurements, as applicable;
(c) Underutilization and over utilization of services;
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Exhibit B – Part II Page 55 of 221
(d) Provider compliance of access standards and follow up actions taken when out
of compliance; and
(e) Assessment of the quality and appropriateness of care furnished to its OHP
Members to DHS annually in the QA/PI program evaluation of the impact and
effectiveness of the QA/PI program 30 days after the termination of this
Agreement.
e. ABHA shall participate as a member of the AMH QA/PI Committee if such
participation is requested by DHS.
3. External Quality Review
a. In conformance with 42 CFR 438 Subpart E, ABHA and its subcontractors and Providers
shall cooperate with AMH by providing access to records and facilities for the purpose of an
annual external, independent professional review of the quality outcomes, timeliness of, and
access to Services provided under this Agreement.
b. If the External Quality Review Organization (HO) identifies an adverse clinical situation in
which follow-up is needed to determine whether appropriate care was provided, the EQRO
shall report the findings to DHS, COIHS; COIHS will provide a copy to ABHA.
c. ABHA shall provide to COIHS, based on the EQRO:
a. An annual PIP validation;
b. An annual performance measurement validation;
c. An information system capabilities assessment conducted every two years; and
d. A compliance review conducted within the previous 3-year period to determine
ABHA’s compliance with standards established by DHS to determine if ABHA shall
develop and comply with a Corrective Action Plan as reviewed and approved by
COIHS.
4. Credentialing Process
a. ABHA shall have written policies and procedures for credentialing and recredentialing
Providers, which includes collecting evidence of credentials and screening the credentials of
Providers, programs and facilities used to deliver Covered Services. These policies and
procedures shall be consistent with OAR 410-141-0120, Oregon Health Plan Prepaid Health
Plan Provision of Health Care Services and shall include verifying possession of valid
licenses or certificates if any are required under any federal, state, or local law, rule, or
regulation to deliver Covered Services in the State of Oregon. These policies and procedures
shall also include collecting proof of liability.
b. ABHA shall submit all changes to its current credentialing and recredentialing policy and
procedure to COIHS for forwarding to DHS for review and approval, as of the effective date
of this Agreement. If there are no changes to the ABHA’s current credentialing and
recredentialing policies and procedures ABHA shall submit Schedules 5.0 and 5.1 as of the
effective date of this Agreement.
Effective: January 1, 2011
Exhibit B – Part II Page 56 of 221
(1) If Participating Providers are not required to be licensed or certified by a State of
Oregon board or licensing agency, then:
(a) Participating Providers must meet the definitions for QMHA or QMHP as
described in Exhibit A, Definitions and Provide Services under the supervision
of a LMP as defined in Exhibit A, Definitions; or
(b) For Participating Providers not meeting either the QMHP or QMHA definition,
ABHA shall document and certify that the person’s education, experience,
competence, and supervision are adequate to permit the person to perform his
or her specific assigned duties.
(2) All programs operated directly or by subcontract must be accredited by nationally
recognized organizations (e.g., Council on Accredited Rehabilitation Facilities
(CARF), TJC and/or are certified under OAR 309-012-0130 et. seq. or licensed under
ORS Chapter 443 by the State of Oregon to deliver specified Services (e.g. OAR 309-
032-0175 through 309-032-1565, Standards for Adult Mental Health Services; OAR
309-032-0950 through 309-032-1080, Standards for Community Treatment Services
for Children; OAR 309-032-1100 through 309-032-1230, Intensive Treatment
Services; and OAR 309-032-1240 through 309-032-1305, Intensive Community
Based Treatment and Support Services; and OAR 309-039-0500 through 309-039-
0580, Standards for Approval of Providers of Non-Inpatient Mental Health Treatment
Services).
(3) Facilities used to deliver services specified in OAR 309-032-0175 through 309-032-
1565, Standards for Regional Acute Care Psychiatric Services for Adults, OAR 309-
033-0700 through 309-033-0740, Standards for the Approval of Community Hospital
and Non-hospital Facilities to Provide Seclusion and Restraint to Committed Persons
in Custody or on Diversion and OAR 309-032-1100 through 309-032-1230 must be
certified or licensed by the State of Oregon and be safe and adequately equipped and
adequately staffed for Covered Services provided.
(4) ABHA shall periodically check that Participating Providers, programs and facilities
are credentialed as specified above.
c. ABHA credentialing records shall document academic degrees, licenses, certifications, and/or
qualifications of Participating Providers, programs and facilities. If the Covered Service is
Acute Inpatient Hospital Psychiatric Care, ABHA need not maintain credentialing records of
hospital staff but shall maintain records documenting that the facility is appropriately
licensed.
d. ABHA’s subcontractors and Participating Providers shall work within the scope of
registration or licensure and qualifications specified above in Items b (1) through b (4) of this
section.
e. ABHA shall collaborate with COIHS in order to provide DHS with a written plan for
transferring the OHP Members and an updated Provider Capacity Assurance Report, Exhibit
K, at least ninety (90) days prior to a Material Change, pursuant to OAR 410-141-0220, (4)
and OAR 410-141-0220, or the termination or loss of a Provider or Provider group or affected
by other factors which have significant impact on access in that Service Area and which may
Effective: January 1, 2011
Exhibit B – Part II Page 57 of 221
result in transferring a substantial number of OHP Members to other Providers employed or
subcontracted with ABHA, notwithstanding the Agreement renewal date. ABHA remains
responsible for maintaining sufficient capacity and solvency, and providing all Capitated
Services through the end of the ninety (90) days period.
f. If ABHA must terminate a Provider or Provider group due to problems that could
compromise the OHP Member’s care, less than the required notice to COIHS and the OHP
Member may be provided.
g. If a Provider or Provider group terminates their Subcontract or employment with ABHA or if
ABHA is affected by circumstances beyond ABHA’s control and the ABHA cannot
reasonably provide the required ninety (90) days notice, less than the required notice to
COIHS may be provided with the approval of COIHS.
h. Pursuant to 42 CFR 438.10(f)(5), ABHA shall provide written notice of termination of a
Participating Provider within 10 days after receipt or issuance of the termination notice,
COIHS and each OHP Members who received care, or was seen on a regular basis, by the
terminated Provider.
i. If ABHA cannot demonstrate sufficient Provider Capacity, COIHS reserves the right to seek
other avenues to Provide Services to OHP Members. If COIHS determines that some or all of
the affected OHP Members must be disenrolled from ABHA, the applicable provisions of the
Agreement shall apply.
j. Facilities used for Acute Inpatient Hospital Psychiatric Care shall have separate units for the
Treatment of children and adults (OHP Members ages 18 and older); or ABHA in
collaboration with COIHS may propose, for DHS approval, an alternative to separate units
which provides for the safety and protection of all Acute Inpatient Hospital Psychiatric Care
patients.
k. ABHA shall have written policies and procedures for selection and retention of Providers.
l. ABHA's provider selection policies and procedures shall not discriminate for the
participation, reimbursement, or indemnification of any provider who is acting within the
scope of his or her license or certification under applicable State law, solely on the basis of
that license or certification. This paragraph shall not be construed to prohibit ABHA from
including Providers only to the extent necessary to meet the needs of OHP Members or from
establishing any measure designed to maintain quality and control costs consistent with
ABHA's responsibilities under this Agreement. This paragraph shall not be construed to
preclude ABHA from using different reimbursement amounts for different specialties or for
different practitioners in the same specialty. If ABHA declines to include individuals or
groups of providers in its network, ABHA must give the affected provider(s) written notice of
the reason for its decision.
m. ABHA's provider selection policies and procedures must not discriminate against particular
providers that serve high-risk populations or specialize in conditions that require costly
treatment. If ABHA declines to include individuals or groups of providers in its network,
ABHA must give the affected provider(s) written notice of the reason for its decision.
5. Services Coordination for Non-Capitated Services
Effective: January 1, 2011
Exhibit B – Part II Page 58 of 221
a. ABHA shall coordinate services for each OHP Member who requires medical assistance
services not covered under the Capitation Payment. ABHA shall arrange, coordinate, and
monitor Non-Capitated Services for chemical dependency and mental health care for that
OHP Member on an ongoing basis, except as provided for in Paragraph (3) of this Section 5.
b. ABHA shall document its professional relationships with Local or Regional Allied Agencies,
as defined in OAR 410-141-0000; community Emergency Service agencies; residential
Chemical Dependency Services Providers; and local Non-Participating Providers which may
offer services that are not Covered Services under the Capitation Payment.
c. ABHA shall not require OHP Members to obtain the approval of a Primary Care Physician in
order to gain access to mental health or alcohol and drug assessment and evaluation services.
OHP Members may refer themselves to MHO services.
Effective: January 1, 2011
Exhibit B – Part III Page 59 of 221
Exhibit B –Statement of Work – Part III – Members
1. Informational Materials and Education of OHP Members
a. ABHA shall assists COIHS in the development of written informational materials and
educational programs as described in OAR 410-141-0280, Oregon Health Plan Prepaid
Health Plan Information Requirements and OAR 410-141-0300, Oregon Health Plan
Prepaid Health Plan Member Education. These materials and programs shall be in a
manner and format that may be easily understood and tailored to the backgrounds and
special needs of OHP Members, for example, are visually limited or have limited reading
proficiency. ABHA shall develop, and make available to its OHP Members, a mental
health education program that addresses Prevention and Early Intervention of mental
illness. ABHA shall offer orientation to new OHP Members within 30 days of Enrollment
that helps them understand the requirements and benefits of the plan. ABHA shall
distribute an OHP Member handbook to new OHP Members within 14 calendar days of
the OHP Member's effective date of coverage with ABHA, which includes the information
in Exhibit Q.
b. ABHA shall provide written notice to OHP Members of any significant changes in
program or policies and procedures at least 30 days before the intended effective date of
the change.
c. Health education shall include: promotion and maintenance of optimal health care status
to include identification of tobacco use, referral for tobacco cessation interventions
(educations material, tobacco cessation groups, pharmacological benefits and the Oregon
Tobacco Quit Line (1-877-270-STOP)).
d. ABHA shall provide additional information that is available upon request by the OHP
Member, including information on ABHA's structure and operations, and Practitioner
Incentive Plans.
e. ABHA shall inform all OHP Members that written information is available in alternative
formats and how to access those formats.
f. ABHA shall make available to OHP Members, or Potential OHP Members, in compliance
with the requirements of the Americans with Disabilities Act of 1990, information in such
alternative formats to allow the individual to effectively receive such information. These
alternative formats may include, but are not limited to culturally appropriate information,
foreign language translations, large print and audio of Braille translations for hearing or
vision impaired OHP Members.
g. ABHA, in partnership with COIHS, shall notify OHP Members that oral interpretation is
available for prevalent non-English language, written information is available in each
prevalent non-English language and how to access those services.
2. OHP Member Rights
a. ABHA shall have written policies and procedures incorporating and ensuring the rights
and responsibilities of OHP Members consistent with any applicable Federal and State
laws, rules, and regulations that pertain to OHP Member rights, and shall ensure that
Effective: January 1, 2011
Exhibit B – Part III Page 60 of 221
ABHA’s staff and Providers take those rights into account when furnishing services to
OHP Members including, but, not limited to ORS 430.210, Rights of Service Recipients;
Status of Rights; OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Member
Rights and Responsibilities; ORS 430.735 through 430.765, Abuse Reporting for the
Mentally Ill; and OAR 410-009-0050 through 410-009-0160, Abuse Reporting and
Protective Services in Community Programs and Community Facilities.
b. ABHA shall furnish to OHP Members information on the rights specified in OAR 410-
141-0320, Oregon Health Plan Prepaid Health Plan Member Rights and Responsibilities.
ABHA shall also make available this same information to Potential OHP Members.
ABHA shall give particular attention to the following rights:
(1) The right to receive Covered Services;
(2) The right to receive information on available treatment options, including a second
opinion and alternatives presented in a manner appropriate to the OHP Member's
condition and ability to understand;
(3) The right to be actively involved in the development of Treatment Plans if Covered
Services are to be provided and to have parents involved in such Treatment
Planning consistent with OAR 309-032-1500 through 309-032-1565, Standards for
Community Treatment Services for Children; OAR 309-032-1100 through 309-
032-1230, Intensive Treatment Services; and OAR 309-032-1240 through 309-
032-1305, Intensive Community Based Treatment and Support Services;
(4) The right to participate in decisions regarding his or her health care, including the
right to refuse Covered Services;
(5) The right to be informed as required in ORS 127.703, Required Policies Regarding
Mental Health Treatment Rights Information; Declaration for Mental Health
Treatment;
(6) The right to request and receive a copy of his or her own Clinical Record, (unless
access is restricted in accordance with ORS 179.505 or other applicable law) and to
request that the records be amended or corrected as specified in 45 CFR Part 164;
(7) The right to privacy and confidentiality and have Clinical Records kept confidential
consistent with applicable Federal and State laws, rules and regulations.
(8) The right to have an opportunity to select an appropriate Mental Health Practitioner
and Service site from within ABHA’s Participating Provider Panel;
(9) The right to refer oneself directly to ABHA for Covered Services without first
having to gain authorization from another Provider;
(10) The right to have access to Covered Services which at least equals access available
to other persons served by ABHA;
(11) The right to receive a Notice of Action when a Service, benefit, Request for Service
Authorization or Request for Claim Payment is denied; or prior to termination,
Effective: January 1, 2011
Exhibit B – Part III Page 61 of 221
suspension or reduction of a benefit or Service as described in Exhibit N,
Grievance System;
(12) The right to file Grievance or Appeal or request a hearing as described in Exhibit
N, a Grievance System;
(13) The right to request an expedited Administrative Hearing if the OHP Member feels
the mental health problem is urgent or emergent and cannot wait for the normal
hearing process;
(14) The right to request Continuation of Benefits until a decision in a hearing is
rendered. The OHP Member may be required to repay any benefits continued if the
issue is resolved in favor of ABHA;
(15) The right to receive, within 30 calendar days of Enrollment, written materials
describing at least the following topics: rights and responsibilities, benefits
available, how to access Covered Services, what to do in an Emergency Situation,
and how to file a Grievance or Appeal, or request a hearing;
(16) The right to have written materials explained in a manner which is understandable;
(17) The right to access protective Services as described in ORS 430.735 through
430.765, Abuse Reporting for Mentally Ill and OAR 410-009-0050 through 410-
009-0160, Abuse Reporting and Protective Services in Community Programs and
Community Facilities;
(18) The right to be treated with respect and with due consideration for his or her dignity
and privacy;
(19) The right to be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation; and
(20) The right to exercise his or her rights, and that the exercise of those rights does not
adversely affect the way ABHA and its Providers treat the OHP Member.
c. ABHA shall post OHP Member rights in a visible location in all clinics, Participating
Provider offices, and other Service locations.
3. Grievances System
a. ABHA shall have written procedures approved in writing by COIHS for accepting,
processing and responding to all Grievances and Appeals from OHP Members, consistent
with the requirements of Exhibit N and OAR 410-141-0260 through 410-141-0266,
including Grievances and Appeals related to requests for accommodation in
communication or provision of Services for OHP Members with a disability or limited
English proficiency. COIHS reviews the ABHA’s procedures for compliance with the
requirements of Exhibit N and OAR 410-141-0260 through 410-141-0266, as well as any
applicable federal requirements, including 42 CFR 438.
Effective: January 1, 2011
Exhibit B – Part III Page 62 of 221
b. Each time a Covered Service or benefit is denied, terminated, suspended or reduced, or
when ABHA authorizes a course of Treatment or Covered Service, but subsequently acts
to terminate, discontinue or reduce the course of Treatment or a Covered Service, ABHA
shall issue a Notice of Action to the affected OHP Member at least 10 Business Days
before the date of the Action, unless there is documentation that the OHP Member had
previously agreed to the change as a part of the course of Treatment. ABHA shall comply
with Exhibit N and the notice requirements in OAR 410-141-0263, Notice of Action by a
PHP, including information about continuation of benefits.
c. In the event an OHP Member or an OHP Member Representative requests an
Administrative Hearing from DHS, ABHA shall comply with the requirements of Exhibit
N and OAR 410-141-0264, Administrative Hearings.
d. ABHA shall maintain a log of all OHP Member Grievances and Appeals. The log shall
identify the OHP Member, the date of the Grievance, the resolution and the date of
resolution. ABHA shall retain Grievance and Appeal logs for 7 (seven) years. This
provision shall survive expiration or termination of this Agreement.
e. ABHA in collaboration with COIHS shall submit to DHS a quarterly report summarizing
OHP Member Grievances, using the report format in Exhibit N, Attachment 1.
f. ABHA and its subcontractors shall cooperate with COIHS and the DHS’ Client Advisory
Services Unit and the AMH Representatives in all of DHS’ activities related to OHP
Member Grievances, Appeals, and Administrative Hearings.
g. ABHA shall inform OHP Members about the ABHA’s Grievance procedures and
timeframes, the availability of assistance in the filing process, the toll-free numbers that an
OHP Member can use to file a Grievance or Appeal by phone, how to request continuation
of benefits (and OHP Member responsibility to pay for the cost of services furnished while
an Appeal or Administrative Hearing is pending if the final decision is adverse to the OHP
Member), and how to access a Administrative Hearing at the time of the OHP Member’s
Enrollment.
4. Enrollment and Disenrollment
a. Enrollment
(1) Enrollment is the process by which DHS signs on with a particular contractor those
individuals who have been determined to be eligible for Services under the OHP.
The provisions of this section apply if Enrollment is mandatory or voluntary and if
the services are delivered by the OHP Member’s PCP or another Provider.
Enrollment is voluntary, except in the case of mandatory Enrollment programs,
pursuant to OAR 410-141-0060. DHS will sign on such individuals with COIHS if
selected by the individual. If an eligible individual does not select a contractor,
DHS may, pursuant to OAR 410-141-0060, Oregon Health Plan Managed Care
Enrollment Requirements, elect to assign the person to a contractor selected by
DHS. COIHS shall have an open Enrollment period at all times, during which
COIHS shall accept, without restriction, all eligible OHP Clients in the order in
which they apply and are signed on with COIHS by DHS, unless COIHS is also a
FCHP and DHS and COIHS have jointly closed Enrollment because COIHS
Effective: January 1, 2011
Exhibit B – Part III Page 63 of 221
maximum Enrollment limit has been reached or for any other reason mutually
agreed to by DHS and COIHS under the FCHP Agreement.
ABHA shall not discriminate, and shall not use any policy or practice that has the
effect of discrimination, against any individual eligible to enroll on the basis of
mental health status or need for Covered Services, on the basis of other Disabilities,
or on the basis of race, color, or national origin.
(2) An individual becomes an OHP Member for purposes of this Agreement as of the
date of Enrollment with COIHS, and as of that date, ABHA shall provide all
Covered Services to such individual as required by the terms of this Agreement.
For persons who are enrolled on the same day as they are admitted to the hospital
or, for children and adolescents admitted to psychiatric residential treatment
services (PRTS), ABHA shall be responsible for said Services. If the person is
enrolled after the first day of hospital stay or PRTS, the person shall be disenrolled,
and the date of Enrollment shall be the next available Enrollment date following
discharge from hospital Services or PRTS.
(3) Enrollment of eligible OHP Clients with COIHS shall occur on a weekly and
monthly basis as described in OAR 410-141-0060, Oregon Health Plan Managed
Care Enrollment Requirements.
(4) DHS will make available enrollment data files via an electronic mailbox.
Enrollment data files on the electronic mailbox shall remain available until COIHS
retrieves them, except where they remain for more than 6 (six) weeks. Any
Enrollment data files remaining in the electronic mailbox for 6 (six) weeks or more
may be removed at DHS’ sole discretion. For the weekly Enrollment process, an
Enrollment data file, which may contain new, current members with changes,
and/or disenrolled OHP Members shall appear in the electronic mailbox Friday
morning of each week. For the monthly Enrollment process, Enrollment data files,
which may contain new, closed, members with changes and/or ongoing OHP
Members for the next month shall appear on the electronic mailbox three business
days following the date of monthly Enrollment cutoff. An Enrollment listing shall
be made available to ABHA by the 15th of the month in which the Enrollments are
applicable.
b. Disenrollment
(1) An individual is no longer an OHP Member eligible for Covered Services under
this Agreement as of the effective date of the OHP Member’s Disenrollment from
COIHS, and as of that date, ABHA is no longer required to Provide Services to
such individual under this Agreement.
(2) An OHP Member may be disenrolled from COIHS as follows:
(a) If requested orally or in writing by the OHP Member or OHP Member
Representative, as specified in OAR 410-141-0000 and 410-141-0080 (1)
(b) for the following reasons:
Effective: January 1, 2011
Exhibit B – Part III Page 64 of 221
(i) With cause:
(A) at any time;
(B) if ABHA does not, because of moral or religious objections,
cover the Service the OHP Member seeks;
(C) if the OHP Member needs related Services to be performed
at the same time and not all related Services are available
within the Provider network and the OHP Member’s primary
care Provider or another Participating Provider receiving the
Services separately would subject the OHP Member to
unnecessary risk;
(D) for other reasons, including, but not limited to, poor Quality
of Care, lack of access to services covered under this
Agreement, or lack of access to Participating Providers
experienced in dealing with the OHP Member's needs, when
the State imposes intermediate sanctions as specified in 42
CFR 438.702 and identified in Exhibit B, Part VI, 2 of this
Agreement; or
(E) if the OHP Member moves out of the COIHS’s Service Area.
(ii) Without cause:
(A) after six months of Enrollment;
(B) whenever the OHP Member's eligibility is re-determined by
DHS (e.g., a recipient who is automatically re-enrolled after
being disenrolled, solely because he or she loses Medicaid
eligibility for a period of 2 months or less), if the temporary
loss of Medicaid eligibility has caused the DMAP Member
to miss the annual Disenrollment opportunity;
(C) if continued Enrollment would be detrimental to the OHP
Member's health;
(D) the OHP Member is a Native American, Alaskan Native; or
(E) for Continuity of Care.
(b) If requested by ABHA, and approved by COIHS, because the OHP
Member:
(i) is unruly or abusive to others;
(ii) threatens or commits an act of physical violence;
Effective: January 1, 2011
Exhibit B – Part III Page 65 of 221
(iii) committed fraudulent or illegal acts such as permitting the use of
OHP Member identification card by another person;
(iv) is suspected of altering a prescription;
(v) is suspected of thefts or other criminal acts committed in any
Provider's or ABHA's premises;
(vi) otherwise misused the Medical Assistance Program;
(vii) is under the jurisdiction of the PSRB; or
(viii) for other reasons specified in OAR 410-141-0080.
(c) If requested by the PSRB for an OHP Member under its jurisdiction.
DHS approval is required for all Disenrollment requests of OHP Members, COIHS,
or PSRB for OHP Members under PSRB jurisdiction.
(3) The effective date of Disenrollment shall be the first of the month following DHS
approval for Disenrollment. If ABHA receives a request for Disenrollment from an
OHP Member, ABHA shall forward the request to COIHS within 5 business days
for forwarding to DHS. If DHS fails to make a Disenrollment determination by the
first day of the second month following the month in which the OHP Member files
a request for Disenrollment, the Disenrollment is considered approved. For OHP
Members under PSRB jurisdiction who are approved for Disenrollment at the
request of ABHA or PSRB, the effective date of Disenrollment may be made
retroactive to the date the OHP Member was enrolled with COIHS or placed under
PSRB jurisdiction, whichever is more recent.
(4) If DHS disenrolls an OHP Member retroactively, any Capitation Payments received
by ABHA for that OHP Member after the effective date of Disenrollment shall be
handled as described in Exhibit C, Section 1.5, Settlement of Accounts.
(5) ABHA shall not request Disenrollment of an OHP Member for reasons related to:
(a) An adverse change in the OHP Member's health status;
(b) Utilization of medical services;
(c) Diminished mental capacity;
(d) Uncooperative or disruptive behavior resulting from the OHP Member's
special needs (except when the continued Enrollment seriously impairs
ABHA's ability to furnish Services to either the OHP Member or other OHP
Members);
(e) A disability or any condition that is a direct result of the OHP Member’s
disability; or
Effective: January 1, 2011
Exhibit B – Part III Page 66 of 221
(f) Other reasons specified in OAR 410-141-0080.
5. [RESERVED]
6. Marketing
ABHA must have in place a mechanism for OHP Members and Potential OHP Members to
receive information to help them understand the requirements and benefits available under this
Agreement. ABHA shall have information available for Potential OHP Members to assist them in
making an informed decision about Enrollment with ABHA. ABHA shall ensure that staff
activities and written materials are accurate and available in both oral and written format and do
not intentionally mislead confuse, or defraud OHP Members or Potential OHP Members about
options available through ABHA. Statements that will be considered inaccurate, false, or
misleading include, but are not limited to, any assertion or statement (whether written or oral) that
the OHP Member must enroll with ABHA in order to obtain benefits or in order not to lose
benefits; or that the ABHA is endorsed by CMS, the federal or state government, or similar entity.
Pursuant to OAR 410-141-0270, ABHA in collaboration with COIHS shall cooperate with DHS in
developing written materials to be included in OHP application packets.
a. ABHA, and subcontractors, shall not initiate contact nor market independently to Potential
OHP Members in an attempt to influence an individual’s Enrollment with COIHS, without
the express written consent of COIHS.
b. Pursuant to OAR 410-141-0270(1), and as defined in OAR 410-141-0000, ABHA and
subcontractors may not conduct, directly or indirectly, door-to-door, telephonic, mail or
other cold call marketing practices to entice Potential OHP Members to enroll with
COIHS, or to not enroll with another DHS contractor.
c. ABHA, and subcontractors, shall not seek to influence an individual’s Enrollment with
COIHS in conjunction with the sale of any other insurance.
d. ABHA and subcontractors may engage in activities intended to Provide Outreach to
COIHS’s enrolled OHP Members for the purpose of enhancing mental health promotion or
education within ABHA’s Service Area.
e. ABHA shall submit to COIHS, for review and approval, all written marketing materials to
OHP Members or Potential OHP Members that reference benefits and/or coverage.
Marketing material shall be made available to all OHP Members, or Potential OHP
Members, within ABHA’s Service Area. Marketing materials expressly for the purpose of
mental health promotion, education or Outreach do not require prior approval.
Effective: January 1, 2011
Exhibit B – Part IV Page 67 of 221
Exhibit B –Statement of Work – Part IV – Financial Matters
1. Financial Risk, Management and Solvency
ABHA shall assume the risk for providing Covered Services to its OHP Members.
ABHA shall provide assurances, as stated in CFR 438.116, to COIHS that ABHA’s
provision(s) against the risk of insolvency are adequate to ensure that OHP Members will
not be liable for ABHA’s debts if ABHA becomes insolvent. ABHA shall maintain risk
protection against catastrophic or unexpected OHP Member expenses related to Covered
Services, and shall maintain protections against insolvency, as specified in Exhibit G,
Solvency Plan and Financial Reporting. If ABHA expects to change any elements of the
Solvency Plan or solvency protection arrangements, ABHA shall provide written advance
notice to COIHS at least forty five (45) calendar days before the proposed effective date
of change. Such changes are subject to written approval from COIHS.
a. Failure to maintain adequate financial solvency, as determined by COIHS, shall
be grounds for termination of this Agreement by COIHS.
b. In the event that insolvency occurs, ABHA remains financially responsible for
providing Covered Services for OHP Members through the end of the period for
which ABHA has been paid, including inpatient admissions up until date of
discharge, except for persons approved for Long Term Psychiatric Care as defined
in Exhibit B, Part II, Section 1, Subsection c, Paragraph (10) of this Agreement.
c. OHP Member shall not be held liable for payments and ABHA shall not bill,
charge, seek compensation, remuneration, or reimbursement from any OHP
Member for:
(a) any debt or payment of claims due to ABHA’s insolvency;
(b) Covered Services provided to the OHP Member for which COIHS did not
pay ABHA;
(c) Covered Services provided to the OHP Member by a Provider under a
contractual, referral, or other arrangement for which Provider did not
receive payment from ABHA; or
(d) Payment for Covered Services provided under a contract, referral, or other
arrangement, other than co-payments, if applicable.
d. ABHA shall not seek recourse against COIHS or DHS for Covered Services
provided during the period for which Capitation Payments were made by COIHS
to ABHA even in the event ABHA becomes insolvent.
Effective: January 1, 2011
Exhibit B – Part IV Page 68 of 221
2. Dual Payment
Except as specifically permitted by this Agreement, ABHA shall not be compensated for
work performed under this Agreement from any other department of the State of Oregon,
nor from any other source including the federal government. ABHA shall immediately
report any funds received by ABHA through activities arising under this Agreement.
Certain federal laws governing reimbursement of Federally Qualified Health Centers,
Rural Health Centers and Indian Health Care Providers may require DHS to provide
supplemental payments to those entities, even though those entities have subcontracted
with ABHA to provide Covered Services and including Indian Health Care Providers that
do not have a subcontract with the ABHA. These supplemental payments are outside the
scope of this Agreement and do not violate the prohibition on dual payments contained
herein. ABHA is required to maintain Encounter Data records and such additional
subcontract information documenting ABHA’s reimbursement to Federally Qualified
Health Clinics, Rural Health Centers and Indian Health Care Providers, and to provide
such information to COIHS or DHS upon request. ABHA is required to provide
information documenting ABHA’s reimbursement to non-participating Indian Health
Care Providers to COIHS or DHS upon request.
3. (Reserved)
4. Financial Reporting Related to Paid Claims
a. ABHA shall submit to COIHS financial reporting related to paid claims, as
specified in Exhibit G., Attachment 8, Report G.7. Failure by ABHA to comply
with the requirements of such reporting will result in Corrective Action and other
such remedies as COIHS may impose under Exhibit B, Part VI, Section 2., of this
Agreement.
b. When Corrective Action has been initiated by COIHS, ABHA may submit
documentation to COIHS citing specific circumstances which delayed ABHA's
timely submittal of Report G.7 - Financial Reporting Related to Paid Claims.
c. COIHS will review the documentation and make a determination within ten (10)
business days to determine if the cited circumstances are acceptable.
Effective: January 1, 2011
Exhibit B – Part V Page 69 of 221
Exhibit B –Statement of Work – Part V – Operations
1. Recordkeeping
a. Clinical Records
ABHA shall maintain recordkeeping consistent with OAR 410-141-0180, Oregon Health Plan
Prepaid Health Plan Recordkeeping. Clinical Records shall document the degree of agreement
or disagreement of the OHP Member, or the legal guardian of the OHP Member, with the
Covered Service and Treatment Plans recommended and explained by the Mental Health
Practitioner. If the Clinical Record does not include a signed and dated consent of the OHP
Member or the legal guardian of the OHP Member to the recommended Covered Service or
Treatment Plan, the Clinical Record shall document the reason such signature is missing.
Clinical Records shall also include the signatures, signature dates, and academic degrees of all
persons providing Covered Services and, if applicable, the signatures, signature dates, and
academic degrees of all persons providing clinical, medical or direct supervision of the case.
Clinical records shall be retained for seven (7) years after the date of services for which claims
are made. If an audit, litigation, research and evaluation, or other action involving the records is
started before the end of the seven (7) year period, the clinical records must be retained until all
issues arising out of the action are resolved.
b. Financial Records
ABHA shall maintain complete and legible financial records pertinent to Covered Services
delivered and Capitation Payments received. Such records shall be maintained in accordance
with accounting principles approved by the American Institute of Certified Public Accountants,
Generally Accepted Accounting Principles (GAAP), and/or other applicable accounting
guidelines such as those outlined in OMB circulars A-87 and A-122.
Financial records, supporting documents, statistical records and all other records pertinent to this
Agreement shall be retained for a period of five (5) years after final payment is made under this
Agreement or until all pending matters are resolved, whichever period is longer. ABHA shall
maintain an appropriate record system for Services to enrolled members and retain records in
accordance with 45 CFR Part 74, unless otherwise specified in applicable Oregon Revised
Statutes or Oregon Administrative Rules.
c. Confidentiality
Except as required by Subsection a., above, ABHA and its agents, employees and subcontractors
shall maintain all OHP Member information and records, whether hard copy or computerized, as
confidential, consistent with OAR 410-141-0180, Oregon Health Plan Prepaid Health Plan
Record Keeping, and Exhibit B, Part V, Section 1, Record Keeping of this Agreement.
(1) For the protection of OHP Members and consistent with the requirements of 42 CFR Part
431, Subpart F and ORS 411.320, ABHA shall not disclose or use the contents of any
records, files, papers or communications for purposes other than those directly connected
with the administration of this Agreement, except with the written consent or
authorization of the OHP Member, his or her attorney, or, the OHP Member
Representative, or except as permitted by ORS 179.505 or by 2007 Senate Bill 163
(Chapter 798, 2007 Laws) and the DHS rules there under.
Effective: January 1, 2011
Exhibit B – Part V Page 70 of 221
(2) If ABHA or its subcontractor is a public body within the meaning of the Oregon Public
Records Law, the ABHA or subcontractor shall ensure that the confidentiality of OHP
Members is maintained in accordance with ORS 192.502(2) (personal privacy
exemption), ORS 192.502(8) (confidential under federal law), and ORS 192.502(9)
(confidential under State law) or other relevant exemptions.
(3) To the extent that information about OHP Members includes confidential protected
health information or records about alcohol and drug abuse treatment, mental health
treatment, HIV/AIDS, and/or genetics, ABHA, its agents, employees and subcontractors
shall comply with the specific confidentiality requirements applicable to such information
or records under federal and State law.
(4) ABHA, its agents, employees and subcontractors shall ensure that confidential records
are secure from unauthorized disclosure. Electronic storage and transmission of
confidential OHP Member information and records shall assure accuracy, backup for
retention, and safeguards against tampering, backdating, or alteration.
d. Public Records Laws
ABHA understands and agrees that information prepared, owned, used or retained by COIHS or
DHS is subject to the Public Records Law, ORS 192.410 et. seq.
2. Contractually Required Reports, Policies and Procedures
ABHA shall submit timely, accurate and complete reports as follows:
The reports listed with an asterisk (*) need only to be submitted by ABHA for initial review and
approval by COIHS. For subsequent COIHS or DHS reviews of these same policies, procedures and
reports, ABHA shall submit Schedule 5, signing the affirmation that these documents have been
approved during a previous contract year and that no revisions have occurred since the initial submission
and COIHS and/or DHS approval. ABHA shall review at least annually all internal policies and
procedures, required to be submitted, reviewed and approved by COIHS.
Except where otherwise noted in this Agreement, ABHA shall provide all required reports to COIHS at
least ten business days prior to the date COIHS must provide the final report to DHS; provided,
however, that financial reports shall be provided to COIHS at least five business days prior to the date
COIHS must provide the final financial report to DHS.
It is understood that all Exhibits listed in this Agreement that call for the reporting of “Mental Health
Services” will be completed in the context of ABHA providing Behavioral Health Services to COIHS
OHP Members. “Behavioral Health Services” are the combination of Mental Health and Chemical
Dependency Services. There will be no requirement to report Mental Health and Chemical Dependency
Services separately, unless DHS shall so require. Services to OHP Members with primary chemical
dependency diagnoses versus primary mental health diagnoses can be identified through analysis of
Encounter Data.
To the extent applicable to a particular report, ABHA reports submitted to COIHS may contain
data for a five county region that is ABHA’s broader service area which is not limited to the
service area’s addressed in this contract. Reports Initially Due on Effective Date of this
Agreement
Effective: January 1, 2011
Exhibit B – Part V Page 71 of 221
(1) *List of Subcontracted Activities and the Entities Performing the Subcontracted
Activities.
(a) See Exhibit D, Section 17 and Schedule 9.
(b) Submission is due on the effective date of this Agreement.
(2) *Practitioner Incentive Plan
(a) See Exhibit M.
(b) Submission is due on:
(i) The effective date of this Agreement,
(ii) Within 20 calendar days of COIHS request, and
(iii) As of the effective date of an amendment extending the Service Area.
(3) *Grievance Systems, including Member Appeal Form and Notice of Denial Letter
(a) See Exhibit B, Part III, Section 3.
(b) Submission due by the effective date of this Agreement or through affirmation
and submission of Schedule 5 and 5.1.
(4) *Third Party Resources and Personal Injury Lien Policy and Procedures
(a) See Exhibit I
(b) Submission due upon request from COIHS or through affirmation and submission
of Schedule 5 and 5.1.
(5) *Utilization Management Policies and Procedures
(a) See Exhibit B, Part I, Section 1, Subsection h, Paragraph (3)
(b) Submission due on
(i) Upon request from COIHS or through affirmation and submission of
Schedule 5 and 5.1.,
(ii) Within 30 calendar days of change or adoption, and
(iii) Within 20 calendar days of COIHS request.
Effective: January 1, 2011
Exhibit B – Part V Page 72 of 221
(6) *OHP Member Information Materials, including Member Handbook and Annual
Notification to OHP Members Regarding Ability to Participate in Activities of
ABHA
(a) See Exhibit B, Part III, Section 1 and Exhibit B, Part II, Section 1, Subsection c,
Paragraph (11).
(b) Submission due on:
(i) The effective date of this Agreement or through affirmation and
submission of Schedule 5 and 5.1., and
(ii) Upon changes – within 15 days before the intended change requiring
revision.
(7) *Mental Health Organization Provider Capacity Assurance Report (PCAR)
(a) ABHA shall submit to COIHS, the Mental Health Provider Capacity Assurance
Report, as described in Exhibit K.
(b) Submission due, upon effective date of this Agreement and immediately upon
significant changes; and
(c) At any time there has been a significant change (as determined by COIHS) in the
ABHA’s operations that would affect adequate Capacity and Services.
(8) *Affirmation of Services not Provided Due to Moral or Religious Reasons
(a) See Schedule 8.
(b) Submission due upon effective date of this Agreement.
(9) *Credentialing and Recredentialing Policy and Procedure
(a) See Exhibit B, Part II, Section 3.b.
(b) Due upon effective date of this Agreement or through affirmation and submission
of Schedule 5.0 and Schedule 5.1.
b. Reports Due Within 20 Business Days of Effective Date of this Agreement
(1) *Proof of Excess Loss Protection/Stop Loss
(a) See Exhibit G.
(b) Submission due within 15 days of effective date of this Agreement
(2) *Key Personnel
ABHA shall submit to COIHS, upon the effective date of this Agreement, and
immediately following any changes, the names telephone numbers, email address and fax
Effective: January 1, 2011
Exhibit B – Part V Page 73 of 221
number for the following key personnel: Chief Executive Officer (CEO)/Chief Financial
Officer (CFO), MHO, Director/Manager, Operations Manager (if applicable), Medical
Director, Contract Liaison, QA/PI Liaison, Administrative Assistant (or applicable title),
Children’s Coordinator, Adult Coordinator, Grievance, Appeals and Hearing Liaison, and
Long Term Psychiatric Care Liaison, and Other.
(a) See Schedule 6.
(b) Submission due on effective date of this Agreement.
(c) Immediately upon changes
(3) *Policy and Procedure: CASII and ECSII Administration
(a) See Exhibit B, Part II, Section 1, Subsection b (8) (c) (vii).
(b) Submission due upon request from COIHS or by affirmation and submission of
Schedule 5 and 5.1.
(4) *Policy and Procedure for Level of Service Intensity Determination
(a) See Exhibit B, Part II, Section 1, Subsection b (8) (c) (vi).
(b) Submission due upon request from COIHS or through affirmation and submission
of Schedule 5 and 5.1.
(5) *Policy and Procedure for Prevention and Detection of Fraud, Waste and Abuse
(a) See Exhibit J.
(b) Submission due within 15 days of effective date of this Agreement or by
affirmation and submission of Schedule 5 and 5.1.
c. Reports Due Within 35 Business Days of the Effective Date of this Agreement
(1) *QA/PI Work Plan
(a) See Exhibit B, Part II, Section 2, Subsection b.
(b) Submission due within 35 days of the effective date of this Agreement.
(c) COIHS shall review the Work Plan within 30 days of receipt.
Effective: January 1, 2011
Exhibit B – Part V Page 74 of 221
d. Fiscal Year End Reporting
(1) *Annual Audited Financial Report
(a) See Exhibit G.
(b) Submission due within 165 calendar days from the end of the ABHA fiscal year.
(2) *G.5: Fiscal Year Cash Flow Analysis
(a) See Exhibit G.
(b) Submission due within 75 calendar days following the end of the ABHA’s fiscal
year.
(3) *G.4: Statement of Revenue and Expenses (Annual Fiscal Year)
(a) See Exhibit G.
(b) Submissions due 45 calendar days following the end of the contract year.
(4) *G.7: Financial Reporting Related to Paid Claims
(a) See Exhibit G.
(b) Submission Due on September 15 of each contract year for the previous contract
year.
(5) *Exhibit K, Attachment 2 , Report K, 1
(a) See Exhibit K - Attachment 1.
(b) Submission due on February 15 of each contract year for the previous contract
year.
e. Reports Due W ithin 45 C alendar Days F ollowing the E nd of E ach C alendar Q uarter
(1) *Evidence of Restricted Reserve
(a) See Exhibit G.
(b) Submission due within 45 calendar days following the end of each calendar
quarter: 06-01, 09-01, 12-01, 03-01.
(2) *G.2 Third Party Resource Collections
(a) See Exhibit G.
(b) 45 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01.
Effective: January 1, 2011
Exhibit B – Part V Page 75 of 221
(3) *G.3 Quarterly Balance Sheet
(a) See Exhibit G.
(b) 45 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01.
(4) *G.4 ABHAs Quarterly Statement of Revenue and Expenses
(a) See Exhibit G.
(b) 45 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01.
(5) *G.4A Health Care Expenses By Service Type
(a) See Exhibit G.
(b) 45 calendar days following the end of each calendar quarter06-01, 09-01, 12-01,
03-01 .
(6) *G.4B Prevention/Education/Outreach (PEO)
(a) See Exhibit G.
(b) 5 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01.
(7) *Grievance Log
(a) See Exhibit B, Part III, Section 3 and Exhibit N, Attachment 1.
(b) 45 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01.
(8) *Level of Service Intensity Determination
(a) See Schedule 4.
(b) 45 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01.
(9) *Integrated Service Array (ISA) Progress Report
(a) See Schedule 7.
(b) Collect data at least once every 90 days.
(c) Submit 45 calendar days following the end of each calendar quarter.
f. Due After Termination of this Agreement
Effective: January 1, 2011
Exhibit B – Part V Page 76 of 221
(1) *QA/PI Work Plan Report
(a) See Exhibit B, Part II. Section 2, Subsection b, Paragraph (iii).
(b) Submission due 30 days after termination of this Agreement for the current
contract cycle.
g. Client Process Monitoring System
(1) *See Schedule 1.
(2) Submission due within 20 business days of initiation of Services and within 20 business
days of termination of Services.
h. Oregon Patient/Resident Care System
(1) *See Schedule 3.
(2) Submission due within 12 hours of admission to Acute Care Inpatient Hospital
Psychiatric Care.
i.
3. Other Reporting Requirements
a. Abuse Reporting and Protective Services
For adult OHP Members, ABHA and Participating Providers shall comply with all protective
Services, investigation and reporting requirements described in OAR 410-009-0050 through 410-
009-0160, Abuse Reporting and Protective Services in Community Programs and Community
Facilities and ORS 430.735 through 430.765, Abuse Reporting for Mentally Ill.
b. Failure to Comply with Data Submission Requirements
ABHA’s failure to submit data in accordance with this Agreement shall be considered in
noncompliance with the terms of this Agreement and shall be grounds for withholding Capitation
Payments as specified in this Agreement pertaining to Remedies Short of Termination.
c. Other Systems
Per 42 CFR 438.242, ABHA shall maintain a health information system that collects, analyzes,
integrates, and reports data on OHP Member and Provider characteristics as specified by DHS in
accordance with OAR 410-141-0320 and OAR 410-120-1280. ABHA shall make collected data
available to COIHS, the State or CMS upon request. The system will have automated capacity
adequate to track changes to and errors in the Enrollment listing, including capability to track
Disenrollments for other than loss of OHP eligibility; track Utilization Management activities;
Grievances and Appeals; coordinate benefits with other payers; collect funds from other payers;
and track claims received, Adjudicated and paid.
Effective: January 1, 2011
Exhibit B – Part V Page 77 of 221
d. (Reserved)
4. Research, Evaluation and Monitoring
a. In addition to submission of data described in Exhibit B, Part V, Section 3, Data Systems, ABHA
in collaboration with COIHS shall cooperate with DHS in collection of information through
Consumer surveys, on-site reviews, medical chart reviews, financial reporting and financial
record reviews, interviews with staff, and other information for the purposes of monitoring
compliance with this Agreement, verification of Services actually provided, and for developing
and monitoring performance objectives. ABHA shall assist COIHS and/or DHS with
development and distribution of survey instruments for use in evaluating integration of Covered
Services in the OHP. ABHA and its subcontractors shall provide access to records and facilities
as described in OAR 410-141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping,
Exhibit B, Part V, Section 1, Recordkeeping and Exhibit B, Part VI and this Section 4, Research,
Evaluation and Monitoring.
b. ABHA in collaboration with COIHS shall assist DHS in developing detailed procedures for
tracking and evaluating potential adverse selection created by the urban and/or rural
environment, as applicable. ABHA shall work with COIHS and DHS to assure that such
procedures include collection and evaluation of information that will enable DHS to compare the
intensity of Covered Services rendered to OHP Members of different Mental Health
Organization models.
c. ABHA, or its subcontractors and Providers shall cooperate with COIHS and DHS for an annual
external, independent professional review of the quality outcomes and timeliness of and access to
services provided in this Agreement as indicated in Exhibit B, Part II.
Effective: January 1, 2011
Exhibit B - -Part VI Page 78 of 221
Exhibit B –Statement of Work – Part VI – Relationship of Parties
1. DHS Compliance Review and Quality Assessment Monitoring
a. DHS will conduct contract compliance and QA/PI monitoring related to this
Agreement. ABHA and its subcontractors shall cooperate in such monitoring and
ABHA shall notify its subcontractors and Participating Providers of such
monitoring, related instructions and request for information.
b. COIHS will provide ABHA twenty (20) calendar days written notice of any
Agreement compliance and QA/PI monitoring activity which requires any action
or cooperation of ABHA as specified in D., below, unless one of the following
conditions exist or is suspected to exist:
(1) Operations of ABHA or its subcontractors or Participating Providers
threaten the health or safety of any OHP Member; or
(2) ABHA or its subcontractors or Participating Providers may act to alter
records or make then unavailable for inspection.
c. Notice of monitoring shall include the date the monitoring shall occur, names of
individuals conducting the monitoring, and instructions and requests for
information.
d. Monitoring procedures may include, but are not limited to, the following:
(1) Entry and inspection of any facility used in the delivery of Covered
Services;
(2) A request for submission to COIHS and/or DHS of copies of documents,
or access to such documents during a site visit, as needed to verify
compliance with this Agreement or state and federal laws, rules and
regulations;
(3) The completion by ABHA of self-assessment checklist or pre-site visit
questionnaires recording the degree of compliance or noncompliance with
specific rule requirements; and
(4) Conduct of interviews with, and administration of questionnaires to
ABHA staff, Participating Providers, Health Care Professionals, Allied
Agencies, and Consumers knowledgeable of Service operations.
e. ABHA shall cooperate with COIHS and DHS in the development of a Corrective
Action Plan to bring ABHA performance in compliance with this Agreement or
state and federal laws, rules and regulations.
Effective: January 1, 2011
Exhibit B - -Part VI Page 79 of 221
COIHS will make available to ABHA a written report of DHS’ findings and conclusions within
sixty (60) calendar days of the completion of the monitoring.
2. Consequences of Remedial Action
a. To the extent that a Notice of Intended Remedial Action is due to actions
conducted by ABHA on behalf of COIHS or due to inactivity on the behalf of
ABHA with relation to a responsibility delegated in this Agreement, COIHS will
issue the Notice of Intended Remedial Action to ABHA with the expectation that
ABHA will work closely with COIHS to resolve those issues identified in the
Notice of Intended Remedial Action. Failure to comply with the sanctions
provided in the Notice of Intended Remedial Action shall be subject to resolution
steps outlined in Section III, D and default sanctions outlined in Exhibit D,
Section 9 of this Agreement.
b. To the extent that Remedial Action is due to actions conducted by ABHA on
behalf of COIHS or due to inactivity on behalf of ABHA with relation to a
responsibility delegated in this agreement, ABHA shall be subject to the sanctions
outlined in the Notice of Remedial Action provided to COIHS from DHS. Such
sanctions may include, but will not be limited to: suspension of enrollment of new
members to ABHA, reduction of members assigned to ABHA, withholding of
capitation payments, financial penalties or contract termination. Any disputes
arising from Remedial Action shall be subject to the resolution steps outlined in
Section III, D default sanctions outlined in Exhibit D, Section 9 of this
Agreement.
Effective: January 1, 2011
Exhibit C Page 80 of 221
Exhibit C – Consideration
1. Payment Types and Rates
1.1 Capitation
COIHS will pay to ABHA the current capitation rates, including administration payments, as
determined by DHS for Mental Health and Chemical Dependency Covered Services for Members
enrolled in Heath Plan in Deschutes, Crook and Jefferson counties. ABHA shall be responsible for
any financial deficit or surplus for satisfying the requirement for the provision and scope of Mental
Health and Chemical Dependency Covered Services as defined by DMAP.
1.2 Date of Payment
COIHS shall make Capitation Payments by the twentieth (20th) of the month to ABHA complete
with Enrollment lists showing current OHP Members enrolled with COIHS by county of residence
and corresponding capitation rate.
1.3 ABHA Provider Compensation Consideration
ABHA contracted and non-contracted Providers shall look only to ABHA for compensation for the
provision of mental health and chemical dependency Covered Services.
1.4 Shared Savings.
COIHS will distribute "Shared Savings" as defined in Exhibit C-1, Section A.5, using the
methodology set forth in Exhibit C-1, Section D.2. Calculation and payment of shared savings will
happen within the time frame established in Exhibit C-1 Section D.2.d.3. Details will be determined
prior to initiation of any Targeted Intervention under Exhibit C-1 Section D. Any of the Key Quality
Indicators set forth in this Agreement may be applicable to any intervention as mutually agreed upon
by COIHS and ABHA.
1.5 Settlement of Accounts
a. If an OHP Member is disenrolled, COIHS may Recoup or ABHA shall refund to COIHS,
Capitation Payments received for the OHP Member for any period after the Disenrollment date.
b. COIHS will have no obligation to make any payments to ABHA for any period(s) during which
ABHA substantially fails to carry out the terms of this Agreement. Any payments received by
ABHA from COIHS for such periods, and any other payments received by ABHA from COIHS
to which ABHA is not entitled under the terms of this Agreement, will be considered an
overpayment and will be recovered from ABHA.
c. Any Capitation Payments received by ABHA that are considered an overpayment may be offset
by any future payments to which ABHA would be entitled under this Agreement.
Effective: January 1, 2011
Exhibit C Page 81 of 221
Exhibit C – Attachment 1 - FOCUSED PATIENT CARE PROGRAM
Statement of Intent
COIHS and ABHA recognize the value of a patient-centric health care program that will
enhance and optimize the delivery of care for Members. COIHS and ABHA agree that the Focused
Patient Care Program (“Focused Care”) goal is that Focused Care Members (defined below) receive
high quality, comprehensive, and efficient healthcare in all healthcare settings, accomplished through
the enhanced role of care coordination in the management of patients who suffer from physical health,
mental health and chemical dependency conditions.
COIHS and ABHA further agree that improved access to care, improved management of
chronic illnesses and improved integration of care will result in improved quality of care and more
effective use of resources. Providing the appropriate care by the proper professional staff at the
appropriate time will reduce the cost inefficiencies associated with historic care delivery inadequacies.
ABHA acknowledges that Focused Care will necessitate the re-design or creation of new
practices in order for this patient-centered, cost efficient model of care to accomplish improved access
and coordination of healthcare services, and COIHS is prepared to implement a new aligned financial
structure which will reward ABHA for their achievement of the key attributes and improvement in the
quality and coordination of care which are the hallmarks Focused Care.
Focused Patient Care Program
A. Definitions. The following defined terms shall have meaning throughout this Exhibit C:
1. Focused Care Members. A defined subset of Oregon Health Plan Members assigned by
DHS and DMAP to COIHS and ABHA for whom targeted interventions shall be
developed and implemented as agreed by COIHS and ABHA.
2. Health Plan Employer Data and Information Set (“HEDIS ®”). HEDIS® is a set of
standardized performance measures designed to ensure that purchasers and consumers
have the information they need to reliably compare the performance of managed health
care plans. HEDIS® is sponsored, supported and maintained by the National Committee
for Quality Assurance (“NCQA”).
3. Intervention. A care delivery change or enhancement, primarily funded by ABHA and
possibly in conjunction with another community organization, which is anticipated to
improve patient care and decrease overall costs for a targeted population of Focused
Care Members.
4. Per Member Per Month (“PMPM”). A unit of measure calculated by COIHS based on
paid amounts divided by the member months for the same time period.
5. Shared Savings. Financial rewards resulting from an Intervention which have the
potential to reward ABHA for achieving the goal of increased quality, improved
coordination of care, and decreased overall costs for targeted Focused Care Members.
B. Focused Care Tenets. In conjunction with COIHS and/or other community providers if
necessary, ABHA will create Interventions for Focused Care Members as set forth in this
Exhibit C-1, to better provide care for Focused Care Members. At a minimum, the following
Effective: January 1, 2011
Exhibit C-1 Page 82 of 221
are necessary components and key attributes to ensure that Focused Care Members receive
high quality, comprehensive and cost-effective healthcare in all healthcare settings:
o Committed and engaged leadership including provider champions to lead
program implementation, and promote information sharing between physical
health, mental health, and chemical dependency providers;
o Integrated holistic management of a Focused Care Member’s co-morbidities;
o A collaborative provider-Focused Care Member relationship, including active
goal setting and patient self-management;
o Aggressive care coordination with a documented plan of care based on a
thorough risk assessment;
o Careful monitoring of patient satisfaction and appropriate follow-up as
necessary;
o Adoption and implementation of the use of health information technology to
promote quality of care, to establish a safe environment in which to receive care,
to protect the security of health information, and to promote the provision of
health information exchange; and
o Compliance with all regulatory and accreditation standards, including, but not
limited to, federal and state regulatory requirements and limitations for incentive
plans, as may be applicable.
C. Key Quality Indicators. COIHS and ABHA agree on the Key Quality Indicators in Section
D.5. The Key Quality Indicators shall be tailored to a specific Intervention (see examples in
Section E) and used to distribute Shared Savings to ABHA as defined in Section D2. COIHS
agrees to measure such parameters and provide feedback and guidance on the measurements
and the overall performance of Focused Care per Section D.3. For those measurements
reported by ABHA to the COIHS , COIHS reserves the right to audit such measurements, upon
reasonable notice to ABHA.
D. Shared Savings. COIHS and ABHA acknowledge and agree that Focused Care must
demonstrate the use of “Best Practices” to consistently and reliably meet the needs of Focused
Care Members while being accountable for the quality, appropriateness, and cost-effectiveness
of the care provided. Therefore, COIHS and ABHA agree that the following shall be
implemented:
1. Targeted Interventions for Focused Care Members. COIHS and ABHA shall mutually
agree on Interventions and the party (anticipated to be ABHA) who will bear the cost of
the Intervention for targeted Focused Care Members, and for whom decreased health
care costs are anticipated to be derived. For each distinct Intervention, a target
population of Focused Care Members will be identified, as well as a corresponding
Target PMPM and Actual PMPM for the service or set of services (ER costs, inpatient
costs, etc.) for which decreased health care costs are anticipated.
2. Methodology. The following methodology will be used to determine Shared Savings:
a. Target PMPM: The Target PMPM shall be mutually agreed upon by COIHS and
ABHA to reflect targeted Focused Care Members and the attributable cost of a
Effective: January 1, 2011
Exhibit C-1 Page 83 of 221
service or set of services for which decreased health care costs are anticipated to
be derived as a result of a specific Intervention.
b. Actual PMPM: The Actual PMPM shall be calculated by (a) aggregating paid
expenses for targeted Focused Care Members which are attributable to the same
Intervention and same service or set of services in (a) above.
c. Costs of Intervention: ABHA, possibly in conjunction with another community
organization, may incur investment costs in the effort to design and implement
patient care programs intended to reduce Actual PMPM. These costs shall be
mutually agreed upon between COIHS and ABHA.
d. Settlement: Target PMPM shall be compared to Actual PMPM plus ABHA’s
cost of Intervention to determine the following:
1. Positive Variance. In the event Actual PMPM plus ABHA’s cost of
Intervention is less than Target PMPM (a “Positive Variance”), then:
a) All of ABHA’s cost of Intervention shall be returned to ABHA, and
then
b) Out of any remaining Positive Variance, up to one hundred percent
(100%) of an amount equivalent to ABHA’s cost of Intervention
shall be paid to ABHA according to the weighted performance on the
Key Quality Indicators outlined in Section D.5. (see Section E,
Example A), and then
c) Any remaining Positive Variance shall be invested in the redesign or
creation of new practices that support improved access to
coordinated, patient-centered care, as mutually agreed upon by
COIHS and ABHA (see Section E, Example B).
2. Negative Variance. In the event Actual PMPM plus ABHA’s cost of
Intervention is more than Target PMPM (a “Negative Variance”), there
will be no Shared Savings. In the event Actual PMPM is less than
Target PMPM, and it is ABHA’s cost of Intervention that creates a
Negative Variance, then a portion of ABHA’s cost of Intervention will
be paid to ABHA, up to the Target PMPM Amount (see Section E,
Example C). In the event Actual PMPM exceeds Target PMPM before
the addition of ABHA’s cost of Intervention, then COIHS will not
reimburse for ABHA’s cost of Intervention, or recoup or attempt to
recoup unanticipated health care costs from ABHA (see Section E,
Example D).
3. Timing of Calculation and Shared Savings Payment . A final
reconciliation of the Shared Savings will be conducted by COIHS no
later than four months (120 days) after the close of the contract period
ending December 31st. Any charges or credits to the Actual Budget that
have occurred since the settlement of the previous contract period are
accounted for in the settlement of the current year. Any amounts due
will be mailed to ABHA no later than one month (31 days) from the end
Effective: January 1, 2011
Exhibit C-1 Page 84 of 221
of the 120 day settlement period described above (five months from the
close of the contract period).
e. Quality of Care. COIHS and ABHA expressly acknowledge and agree that
Focused Care does not include any financial incentives for COIHS or ABHA
which would encourage the denial of coverage, withholding of care or service to
Focused Care Members. COIHS and ABHA must demonstrate continuous and
sustained improvement in the quality or care rendered to Focused Care
Members.
f. Focused Care Target PMPM Annual Adjustment. COIHS and ABHA agree that
the Focused Care Target PMPM set forth herein will be based on a calendar year
(January 1 through December 31) with adjustments implemented annually for
expected trends in medical expense. Adjustments will be effective each January
1. The basis and methodology for such adjustment(s) shall be fully disclosed to
ABHA as soon as reasonably possible.
3. Reporting. COIHS shall provide ABHA with periodic reports as necessary to assist
ABHA in managing the care of Focused Care Members, to provide specific feedback
and guidance on overall performance to clearly disclose the outcomes and the results of
Focused Care.
a. Operational Experience Reports. On a monthly basis, COIHS shall provide to
ABHA a report which will include the operational experience and certain Key
Quality Indicators of Focused Care Members. This shall include but not be
limited to hospital/SNF and rehabilitation admissions and readmissions
days/1000, ER visits/1000, outlier watch lists, and other quality indicators as
mutually agreed upon by COIHS and ABHA.
b. Financial Reports. On a quarterly basis, COIHS shall provide to ABHA a report
which will include the YTD Actual PMPM of all targeted Focused Care
Members and calculate the Shared Savings (minus any Costs of Intervention) for
that applicable time period. COIHS shall include an estimate of those claims
incurred, but not yet reported, in order to arrive at the estimated Shared Savings
for that applicable time period. The final reconciliation and settlement of the
Shared Savings shall be calculated in accordance with Section D.2. and D.5.
4. Focused Care Committee. COIHS and ABHA agree to the creation of a joint Focused
Care Committee made up of representatives of COIHS , ABHA and any other invited
organizations, to address issues regarding the operational and clinical efficiencies and
performance associated with relevant personnel participating in Focused Care. Further,
the Focused Care Committee shall be responsible to monitor Focused Care including,
but not limited to the continuous improvement of the health status of Focused Care
Members participating in Focused Care, the attainment of the goals pertaining to
providing the highest possible quality and efficiency for Focused Care Members.
Effective: January 1, 2011
Exhibit C-1 Page 85 of 221
5. Key Quality Indicators. Any of the following Key Quality Indicators may be applicable
to any Intervention as mutually agreed upon by COIHS and ABHA.
Focused Care Key Quality Indicator Target Data Source Weighting
1 Focused Care Members with chronic diseases
(COPD, CV disease, Diabetes) will be screened
or treated for depression.
>65% ABHA
2 A patient satisfaction survey will be created
and distributed to Focused Care Members.
>30% return
rate
ABHA
3
Total Admissions per thousand decreased by
10% vs. baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
4
Total 30-day Readmission Rate decreased by
10% vs. baseline at St. Charles Medical Center
(Bend) for Focused Care Members.
10% decrease
vs. baseline
SCMC Census
Data
5 Chronic Pain Management Program developed
and implemented for Focused Care Members.
Pain mgmt
services
provided to
___ patients
ABHA
6
ER visits per thousand decreased by 10% vs.
baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
METHODOLOGY
Specifications to be agreed to by COIHS and ABHA:
• Measure # 1 - Screening Tool for Depression (and action plans to treat depression).
COIHS and ABHA will mutually need to determine screening tool.
• Measures #3, 4, and 6 - Agreed upon 10% decreases vs. baseline for Focused Care
Members.
• Measure #5 - Summary narrative of program description, implementation process and
number of Focused Care Members who received services must be provided.
Effective: January 1, 2011
Exhibit C-1 Page 86 of 221
Example A:
ABHA implements a Readmission Avoidance Intervention which COIHS and ABHA agree
costs $102,000 and will benefit a targeted Focused Care Member population of 350 patients.
COIHS determines baseline annual attributable cost for these 350 Focused Care Members, for
the set of services (emergency room visits & IP care at St. Charles) expected to be impacted
by the Intervention is $1,000,000. COIHS and ABHA agree on the Key Quality Indicators,
and their relative weighting, to measure at year end. They include indicators 3, 4 and 6. It is
expected some of the Focused Care Members will disenroll mid-year.
350 Focused Care Members x 12 months = 4,200 member months
Annual cost of IP care and ER visits for these 350 Focused Care Members = $1,000,000
Target PMPM = $1,000,000 / 4,200 or $238.10 PMPM.
By end of year, there are 312 (avg) Focused Care Members x 12 mos = 3744 member months
Annual cost of emergency room visits for these 312 Focused Care Members = $700,000
Actual PMPM = $700,000 / 3744 or $186.97 PMPM.
Target PMPM $238.10 PMPM
Actual PMPM $186.97 PMPM
Positive Variance $51.13 PMPM x 3744 member months = $191, 430.72
ABHA Intervention Cost paid to ABHA ($102,000.00)
Remaining Positive Variance $ 89,430.72
Focused Care Key Quality Indicator Target Data Source Weighting
1 Focused Care Members with chronic diseases
(COPD, CV disease, Diabetes) will be screened
or treated for depression.
>65% ABHA
2 A patient satisfaction survey will be created
and distributed to all Focused Care Members.
>30% return
rate
ABHA
3
Total Admissions per thousand decreased by
10% vs. baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
25%
4
Total 30-day Readmission Rate decreased by
10% vs. baseline at St. Charles Medical Center
(Bend) for Focused Care Members.
10% decrease
vs. baseline
SCMC Census
Data
65%
5 Chronic Pain Management Program developed
and implemented for Focused Care Members.
____ patients
received these
services
ABHA
6
ER visits per thousand decreased by 10% vs.
baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
10%
Effective: January 1, 2011
Exhibit C-1 Page 87 of 221
COIHS and ABHA agree that indicators #3, #4 and #6 were met. ABHA is therefore eligible
for 100% of its cost of Intervention from the remaining Positive Variance, however the
remaining Positive Variance is less than the ABHA cost of Intervention, so ABHA will only
get the remaining Positive Variance.
Remaining Positive Variance $89,430.72
100% of ABHA’s $102,000 Intervention Cost per
Key Quality Indicator scoring of #3, #4 and #6 ($89,430.72)
Remaining Positive Variance to be invested in redesign
or creation of new practices that support
improved access to coordinated, patient-centered
care, as agreed by COIHS and ABHA $ 0
Effective: January 1, 2011
Exhibit C-1 Page 88 of 221
E. Example B:
ABHA implements a Chronic Pain Management Program Intervention which COIHS and
ABHA agree costs $80,000 and will benefit a targeted Focused Care Member population of
500 patients. COIHS determines baseline annual attributable cost for these 500 Focused Care
Members, for the set of services (all emergency room visits) expected to be impacted by the
Intervention is $500,000. COIHS and ABHA agree on the Key Quality Indicators, and their
relative weighting, to measure at year end (see below). They include indicators 2, 5, and 6. It
is expected some of the Focused Care Members will disenroll mid-year.
500 Focused Care Members x 12 months = 6,000 member months
Annual cost of all emergency room visits for these 500 Focused Care Members = $500,000
Target PMPM = $500,000 / 6,000 or $83.33 PMPM.
By end of year, there are 490 (avg) Focused Care Members x 12 mos = 5880 member months
Annual cost of all emergency room visits for these 490 Focused Care Members = $300,000
Actual PMPM = $300,000 / 5880 or $51.02 PMPM.
Target PMPM $83.33 PMPM
Actual PMPM $51.02 PMPM
Positive Variance $32.31 PMPM x 5880 member months = $189,394.80
ABHA Intervention Cost paid to ABHA ($ 80,000.00)
Remaining Positive Variance $109,394.80
Focused Care Key Quality Indicator Target Data Source Weighting
1 Focused Care Members with chronic diseases
(COPD, CV disease, Diabetes) will be screened
or treated for depression.
>65% ABHA
2 A patient satisfaction survey will be created
and distributed to all Focused Care Members.
>30% return
rate
ABHA 10%
3
Total Admissions per thousand decreased by
10% vs. baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
4
Total 30-day Readmission Rate decreased by
10% vs. baseline at St. Charles Medical Center
(Bend) for Focused Care Members.
10% decrease
vs. baseline
SCMC Census
Data
5 Chronic Pain Management Program developed
and implemented for Focused Care Members.
____ patients
received these
services
ABHA 20%
6
ER visits per thousand decreased by 10% vs.
baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
70%
Effective: January 1, 2011
Exhibit C-1 Page 89 of 221
COIHS and ABHA agree that indicators #5 and #6 were met, but not indicator #2. ABHA is
therefore eligible for 90% of its Intervention Cost from the remaining Positive Variance.
Remaining Positive Variance $109,394.80
90% of ABHA’s $80,000 Intervention Cost per
Key Quality Indicator scoring of #5 and #6 ($72,000.00)
Remaining Positive Variance to be invested in redesign
or creation of new practices that support
improved access to coordinated, patient-centered
care, as agreed by COIHS and ABHA $37,394.80
Effective: January 1, 2011
Exhibit C-1 Page 90 of 221
Example C:
ABHA implements a Depression Screening with Chronic Disease Intervention which COIHS
and ABHA agree costs $90,000 and will benefit a targeted Focused Care Member population
of 900 patients. COIHS determines baseline annual attributable cost for these 900 Focused
Care Members, for the set of services (inpatient care at St. Charles Med Ctr) expected to be
impacted by the Intervention is $500,000. COIHS and ABHA agree on the Key Quality
Indicators, and their relative weighting, to measure at year end. They include indicators 1 and
3. It is expected some of the Focused Care Members will disenroll mid-year.
900 Focused Care Members x 12 months = 10,800 member months
Annual cost of IP care at St. Charles for these 900 Focused Care Members = $500,000
Target PMPM = $500,000 / 10,800 or $46.30 PMPM.
By end of year, there are 800 (avg) Focused Care Members x 12 mos = 9600 member months
Annual cost of emergency room visits for these 800 Focused Care Members = $420,000
Actual PMPM = $420,000 / 9600 or $43.75 PMPM.
Target PMPM $46.30 PMPM
Actual PMPM $43.75 PMPM
Positive Variance $ 2.55 PMPM x 9600 member months = $ 24,480
ABHA Intervention Cost paid to ABHA ($ 24,480)
Remaining Positive Variance $ 0
Focused Care Key Quality Indicator Target Data Source Weighting
1 Focused Care Members with chronic diseases
(COPD, CV disease, Diabetes) will be screened
or treated for depression.
>65% ABHA 50%
2 A patient satisfaction survey will be created
and distributed to all Focused Care Members.
>30% return
rate
ABHA
3
Total Admissions per thousand decreased by
10% vs. baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
50%
4
Total 30-day Readmission Rate decreased by
10% vs. baseline at St. Charles Medical Center
(Bend) for Focused Care Members.
10% decrease
vs. baseline
SCMC Census
Data
5 Chronic Pain Management Program developed
and implemented for Focused Care Members.
____ patients
received these
services
ABHA
6
ER visits per thousand decreased by 10% vs.
baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
Effective: January 1, 2011
Exhibit C-1 Page 91 of 221
COIHS and ABHA agree that indicators #1 was met, but not indicator #3. ABHA is therefore
eligible for 50% of its cost of Intervention, however there is no remaining Positive Variance.
Remaining Positive Variance $ 0
50% of ABHA’s $90,000 Intervention Cost per
Key Quality Indicator scoring of #1 ($ 0)
Remaining Positive Variance to be invested in redesign
or creation of new practices that support
improved access to coordinated, patient-centered
care, as agreed by COIHS and ABHA $ 0
Effective: January 1, 2011
Exhibit C-1 Page 92 of 221
Example D:
ABHA implements a Depression Screening with Chronic Disease Intervention which COIHS
and ABHA agree costs $90,000 and will benefit a targeted Focused Care Member population
of 900 patients. COIHS determines baseline annual attributable cost for these 900 Focused
Care Members, for the set of services (inpatient care at St. Charles Med Ctr) expected to be
impacted by the Intervention is $500,000. COIHS and ABHA agree on the Key Quality
Indicators, and their relative weighting, to measure at year end. They include indicators 1 and
3. It is expected some of the Focused Care Members will disenroll mid-year.
900 Focused Care Members x 12 months = 10,800 member months
Annual cost of IP care at St. Charles for these 900 Focused Care Members = $500,000
Target PMPM = $500,000 / 10,800 or $46.30 PMPM.
By end of year, there are 800 (avg) Focused Care Members x 12 mos = 9600 member months
Annual cost of emergency room visits for these 800 Focused Care Members = $480,000
Actual PMPM = $480,000 / 9600 or $50.00 PMPM.
Target PMPM $46.30 PMPM
Actual PMPM $50.00 PMPM
Negative Variance ($ 3.70 PMPM) x 9600 member months = ($ 35,520)
ABHA Intervention Cost paid to ABHA $ 0______
Remaining Variance $ 0
Focused Care Key Quality Indicator Target Data Source Weighting
1 Focused Care Members with chronic diseases
(COPD, CV disease, Diabetes) will be screened
or treated for depression.
>65% ABHA 50%
2 A patient satisfaction survey will be created
and distributed to all Focused Care Members.
>30% return
rate
ABHA
3
Total Admissions per thousand decreased by
10% vs. baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
50%
4
Total 30-day Readmission Rate decreased by
10% vs. baseline at St. Charles Medical Center
(Bend) for Focused Care Members.
10% decrease
vs. baseline
SCMC Census
Data
5 Chronic Pain Management Program developed
and implemented for Focused Care Members.
____ patients
received these
ABHA
Effective: January 1, 2011
Exhibit C-1 Page 93 of 221
services
6
ER visits per thousand decreased by 10% vs.
baseline for Focused Care Members.
10% decrease
vs. baseline
Milliman Data
Reports
COIHS and ABHA agree that indicators #1 was met, but not indicator #3. ABHA is therefore
eligible for 50% of its cost of Intervention, however there is no remaining Positive Variance.
Remaining Variance $ 0
50% of ABHA’s $90,000 Intervention Cost per
Key Quality Indicator scoring of #1 ($ 0)
Remaining Variance to be invested in redesign
or creation of new practices that support
improved access to coordinated, patient-centered
care, as agreed by COIHS and ABHA $ 0
Effective: January 1, 2011
Exhibit D Page 94 of 221
Exhibit D – Standard Terms and Conditions
1. Governing Law, Consent to Jurisdiction
This Agreement shall be governed by and construed in accordance with the laws of the State of
Oregon, without regard to principles of conflicts of law. Any claim, action, suit or proceeding
(collectively, the “claim”) between COIHS and ABHA that arises from or relates to this
Agreement shall be brought and conducted solely and exclusively within the Circuit Court of
Deschutes County for the State of Oregon, provided, however, if a claim must be brought in a
federal forum, then it shall be conducted solely and exclusively within the United States
District Court for the District of Oregon. ABHA, BY EXECUTION OF THIS AGREEMENT, HEREBY
CONSENTS TO THE IN PERSONAM JURISDICTION OF SAID COURTS.
2. Compliance with Applicable Law
a. ABHA shall comply and cause all subcontractors to comply with all state and local
laws, regulations, executive orders and ordinances, applicable to this Agreement or to
the performance of Work as they may be adopted, amended or repealed from time to
time, including but not limited to the following: (i) ORS Chapter 659A.142; (ii) DHS
rules pertaining to the provision of prepaid capitated health care and services, OAR
Chapter 410, Division 141; (iii) all other DHS Rules in OAR Chapter 410; and (iv) all
other applicable requirements of state civil rights and rehabilitation statutes, rules and
regulations;. These laws, regulations, executive orders and ordinances are incorporated
by reference herein to the extent that they are applicable to this Agreement and required
by law to be so incorporated. COIHS performance under this Agreement is conditioned
upon ABHA's compliance with the provisions of ORS 279B.220, 279B.230, 279B.235
and 279B.270, which are incorporated by reference herein. ABHA shall, to the
maximum extent economically feasible in the performance of this Agreement, use
recycled paper (as defined in ORS 279A.010(1)(gg)), recycled PETE products (as
defined in ORS 279A.010(1)(hh)), and other recycled products (as "recycled product" is
defined in ORS 279A.010(1)(ii)).
b. In compliance with the Americans with Disabilities Act, any written material that is
generated and provided by ABHA under this Agreement to COIHS clients, including
Medicaid-eligible individuals, shall, at the request of such COIHS clients, be
reproduced in alternate formats of communication, to include Braille, large print,
audiotape, oral presentation, and electronic format. COIHS shall not reimburse ABHA
for costs incurred in complying with this provision. ABHA shall cause all
subcontractors under this Agreement to comply with the requirements of this provision.
c. ABHA shall comply with the federal laws as set forth or incorporated, or both, in this
Agreement and all other federal laws, applicable to ABHA's performance under this
Agreement as they may be adopted, amended or repealed from time to time.
3. Independent Contractor
a. ABHA is not an officer, employee, or agent of the State of Oregon, as those terms are
used in ORS 30.265 or otherwise, nor of COIHS.
Effective: January 1, 2011
Exhibit D Page 95 of 221
b. If ABHA is currently performing work for the State of Oregon or the federal
government, ABHA by signature to this Agreement, represents and warrants that
ABHA's Work to be performed under this Agreement creates no potential or actual
conflict of interest as defined by ORS Chapter 244 and that no statutes, rules or
regulations of the State of Oregon or federal agency for which ABHA currently
performs work would prohibit ABHA's Work under this Agreement. If compensation
under this Agreement is to be charged against federal funds, ABHA certifies that it is
not currently employed by the federal government.
c. ABHA is responsible for all federal and state taxes applicable to compensation paid to
ABHA under this Agreement and, unless ABHA is subject to backup withholding,
COIHS will not withhold from such compensation any amounts to cover ABHA's
federal or state tax obligations. ABHA is not eligible for any social security,
unemployment insurance or workers' compensation benefits from compensation paid to
ABHA under this Agreement, except as a self-employed individual.
d. ABHA shall perform all Work as an independent contractor. COIHS reserves the right
(i) to determine and modify the delivery schedule for the Work and (ii) to evaluate the
quality of the Work Product, however, COIHS may not and will not control the means
or manner of ABHA's performance. ABHA is responsible for determining the
appropriate means and manner of performing the Work.
4. Representations and Warranties
a. ABHA's Representations and Warranties ABHA represents and warrants to COIHS
that:
(1) ABHA has the power and authority to enter into and perform this Agreement,
(2) This Agreement, when executed and delivered, shall be a valid and binding
obligation of ABHA enforceable in accordance with its terms,
(3) ABHA has the skill and knowledge possessed by well-informed members of its
industry, trade or profession and ABHA will apply that skill and knowledge
with care and diligence to perform the Work in a professional manner and in
accordance with standards prevalent in ABHA's industry, trade or profession,
(4) ABHA shall, at all times during the term of this Agreement, be qualified,
professionally competent, and duly licensed to perform the Work, and
(5) Any license or certification required to by law or regulation held by ABHA or
its subcontractors to provide services required by this Agreement is for any
reason denied, revoked or not renewed, provided that immediate corrective
action taken by ABHA or the subcontractor to limit or remove the person whose
license or certification is so impacted from providing required services shall
remedy any violation.
Effective: January 1, 2011
Exhibit D Page 96 of 221
b. Warranties cumulative. The warranties set forth in this section are in addition to, and
not in lieu of, any other warranties provided.
c. Duties of ABHA subject to appropriation by governing body. In the event that any
duty, representation or warranty made by ABHA under this Agreement crosses fiscal
years, all such duties, representations and warranties are subject to approval of
appropriations by the ABHA governing body for that fiscal year.
5. Time is of the Essence
ABHA agrees that time is of the essence under this Agreement.
6. Funds Available and Authorized
a. ABHA shall not be compensated for Work performed under this Agreement by any
other agency or department of the State of Oregon or the federal government. COIHS
represents that DHS has certified that DHS has sufficient funds currently authorized for
expenditure to finance costs of this Agreement within DHS’s current biennial
appropriation or limitation. ABHA understands and agrees that COIHS payment for
Work performed is contingent on COIHS receiving funds from DHS, or other
expenditure authority sufficient to allow COIHS, in the exercise of its reasonable
discretion, to continue to make payments under this Agreement.
b. All billings and payments processed through the Medicaid Management Information
System (MMIS) shall be processed in accordance with the provisions of Oregon
Administrative Rules (OAR) 407-120-0100 through 407-120-0200, OAR 407-120-0300
through OAR 407-120-0380 and any other DHS Oregon Administrative Rules that are
program specific to the billings and payments and, if applicable, to billing and payment
of Medicaid services.
7. Recovery of Overpayments
If payments under this Agreement, or under any other contract between ABHA and COIHS,
result in payments to ABHA to which ABHA is not entitled, COIHS, after giving written
notification to ABHA, may withhold from payments due to ABHA such amounts, over such
periods of time, as are necessary to recover the amount of the overpayment.
8. Indemnification
a. GENERAL INDEMNITY. ABHA SHALL DEFEND, SAVE, HOLD HARMLESS AND INDEMNIFY
THE STATE OF OREGON, DHS, COIHS AND THEIR OFFICERS, EMPLOYEES AND AGENTS
FROM AND AGAINST ALL CLAIMS, SUITS, ACTIONS, LOSSES, DAMAGES, LIABILITIES, COSTS
AND EXPENSES OF ANY NATURE WHATSOEVER (INCLUDING REASONABLE ATTORNEYS'
FEES AND EXPENSES AT TRIAL, ON APPEAL AND IN CONNECTION WITH ANY PETITION FOR
REVIEW) RESULTING FROM, ARISING OUT OF, OR RELATING TO THE ACTIVITIES OF ABHA
OR ITS OFFICERS, EMPLOYEES, SUBCONTRACTORS OR AGENTS UNDER THIS AGREEMENT;
PROVIDED, THAT DHS AND/OR COIHS SHALL PROVIDE ABHA WITH PROMPT WRITTEN
NOTICE OF ANY SUCH CLAIM, SUIT, ACTION OR PROCEEDING AND REASONABLE
ASSISTANCE, AT ABHA’S EXPENSE, IN THE DEFENSE THEREOF.
Effective: January 1, 2011
Exhibit D Page 97 of 221
b. INDEMNITY FOR INFRINGEMENT CLAIMS. WITHOUT LIMITING THE GENERALITY OF
SECTION 8 a., ABHA SHALL DEFEND, SAVE, HOLD HARMLESS, AND INDEMNIFY THE STATE
OF OREGON, DHS, COIHS AND THEIR OFFICERS, EMPLOYEES AND AGENTS FROM AND
AGAINST ALL CLAIMS, SUITS, ACTIONS, LOSSES, DAMAGES, LIABILITIES, COSTS AND
EXPENSES (INCLUDING REASONABLE ATTORNEYS FEES AND EXPENSES AT TRIAL, ON
APPEAL AND IN CONNECTION WITH ANY PETITION FOR REVIEW) RESULTING FROM, ARISING
OUT OF, OR RELATED TO ANY CLAIMS THAT THE WORK, THE WORK PRODUCT OR ANY
OTHER TANGIBLE OR INTANGIBLE ITEMS DELIVERED TO DHS AND/OR COIHS BY ABHA
THAT MAY BE THE SUBJECT OF PROTECTION UNDER ANY STATE OR FEDERAL
INTELLECTUAL PROPERTY LAW OR DOCTRINE, OR DHS AND/OR COIHS’S USE THEREOF,
INFRINGES ANY PATENT, COPYRIGHT, TRADE SECRET, TRADEMARK, TRADE DRESS, MASK
WORK, UTILITY DESIGN, OR OTHER PROPRIETARY RIGHT OF ANY THIRD PARTY; PROVIDED,
THAT DHS AND/OR COIHS SHALL PROVIDE ABHA WITH PROMPT WRITTEN NOTICE OF
ANY INFRINGEMENT CLAIM AND REASONABLE ASSISTANCE, AT ABHA’S EXPENSE IN THE
DEFENSE THEREOF.
c. CONTROL OF DEFENSE AND SETTLEMENT. ABHA SHALL HAVE CONTROL OF THE
DEFENSE AND SETTLEMENT OF ANY CLAIM THAT IS SUBJECT TO THIS SECTIONS 8.a. OR 8.b;
HOWEVER, NEITHER ABHA NOR ANY ATTORNEY ENGAGED BY ABHA, SHALL DEFEND
THE CLAIM IN THE NAME OF THE STATE OF OREGON OR ANY AGENCY OF THE STATE OF
OREGON, NOR PURPORT TO ACT AS LEGAL REPRESENTATIVE OF THE STATE OF OREGON OR
ANY OF ITS AGENCIES, WITHOUT FIRST RECEIVING FROM THE OREGON ATTORNEY
GENERAL AUTHORITY TO ACT AS LEGAL COUNSEL FOR THE STATE OF OREGON. NOR
SHALL ABHA SETTLE ANY CLAIM ON BEHALF OF THE STATE OF OREGON WITHOUT THE
APPROVAL OF THE ATTORNEY GENERAL, NOR ON BEHALF OF COIHS WITHOUT THE
APPROVAL OF COIHS. THE STATE OF OREGON MAY, AT ITS ELECTION AND EXPENSE,
ASSUME ITS OWN DEFENSE AND SETTLEMENT IN THE EVENT THAT THE STATE OF OREGON
DETERMINES THAT ABHA IS PROHIBITED FROM DEFENDING THE STATE OF OREGON, IS
NOT ADEQUATELY DEFENDING THE STATE OF OREGON’S INTERESTS, AN IMPORTANT
GOVERNMENTAL PRINCIPLE IS AT ISSUE, OR IT IS IN THE BEST INTEREST OF THE STATE OF
OREGON TO DO SO, AND THE STATE OF OREGON DESIRES TO ASSUME ITS OWN DEFENSE;
THE SAME RIGHTS ARE GRANTED HEREIN TO COIHS.
d. THE OBLIGATIONS OF THIS SECTION 8 ARE SUBJECT TO THE LIMITATIONS IN SECTION 10
OF THIS EXHIBIT.
9. Default; Remedies and Termination
a. Default by ABHA. ABHA shall be in default under this Agreement if:
(1) ABHA institutes or has instituted against it insolvency, receivership or
bankruptcy proceedings, makes an assignment for the benefit of creditors, or
ceases doing business on a regular basis; or
(2) ABHA no longer holds a license or certificate that is required for ABHA to
perform its obligations under this Agreement and ABHA has not obtained such
license or certificate within 14 calendar days after COIHS notice or such longer
period as COIHS may specify in such notice; or
Effective: January 1, 2011
Exhibit D Page 98 of 221
(3) ABHA commits any material breach or default of any covenant, warranty,
obligation or agreement under this Agreement, fails to perform the Work under
this Agreement within the time specified herein or any extension thereof, or so
fails to pursue the Work as to endanger ABHA’s performance under this
Agreement in accordance with its terms, and such breach, default or failure is
not cured within 14 calendar days after COIHS notice, or such longer period as
COIHS may specify in such notice; or
(4) ABHA knowingly has a director, officer, partner or person with beneficial
ownership of more than 5% of ABHA’s equity or has an employment,
consulting or other subcontractor agreement for the provision of items and
services that are significant and material to ABHA’s obligations under this
Agreement, concerning whom:
(a) Any license or certificate required by law or regulation to be held by
ABHA or subcontractor to Provide services required by this Agreement
is for any reason denied, revoked or not renewed;
(b) Is suspended, debarred or otherwise excluded from participating in
procurement activities under Federal Acquisition Regulation or from
participating in non-procurement activities under regulations issued
pursuant to Executive Order No. 12549 or under guidelines
implementing such order;
(c) Is suspended or terminated from the Oregon Health Plan program or
excluded from participation in the Medicare program; or
(d) Is convicted of a felony or misdemeanor related to a crime or violation of
Title XVIII, XIX, or XX of the Social Security Act or related laws (or
entered a plea of nolo contendere).
(5) If COIHS determines that health or welfare of OHP Members is in jeopardy if
this Agreement continues; or
(6) If COIHS determines:
(a) That amendment of this Agreement is required due to change(s) in
federal or State law or regulations, or due to changes in Covered
Services or Capitation Payments under ORS 414.735;
(b) That failure to amend this Agreement to execute those changes in the
time and manner proposed in the amendment may place COIHS at risk
of non-compliance with federal or State statute or regulations or changes
required by the Legislative Assembly or the Legislative Emergency
Board;
(c) That ABHA does not accept the amendment; or
Effective: January 1, 2011
Exhibit D Page 99 of 221
(d) That ABHA failed to execute the amendment to this Agreement within
the time allowed.
b. COIHS Remedies for ABHA’s Default. In the event ABHA is in default under
Section 9.a., above, COIHS may, at its option, pursue any or all of the remedies
available to it under this Agreement and at law or in equity, including, but not limited
to:
(1) Termination of this Agreement under Section 9.e.(3) below;
(2) Withholding all monies due for Work and Work Products that ABHA has failed
to deliver within any scheduled completion dates or has performed inadequately
or defectively;
(3) Remedies under Exhibit B, Part VI, Section 2 of this Agreement;
(4) Initiation of an action or proceeding for damages, specific performance,
declaratory or injunctive relief; and
(5) Exercise of its right of recovery of overpayments under Section 7 of this Exhibit
or setoff or both.
These remedies are cumulative to the extent the remedies are not inconsistent, and
COIHS may pursue any remedy or remedies singly, collectively, successively or in any
order whatsoever. If a court determines that ABHA was not in default under Section
9.a. above, then ABHA shall be entitled to the same remedies as if this Agreement was
terminated pursuant to Section 9.e.(2) below.
c. Default by COIHS. COIHS shall be in default under this Agreement if COIHS
commits any material breach or default of any covenant, warranty, or obligation under
this Agreement, and such breach or default is not cured within 30 calendar days after
ABHA’s notice or such longer period as ABHA may specify in such notice.
d. ABHA’s Remedies for COIHS Default. In the event COIHS terminates this
Agreement under Section 9.e.(2) below, or in the event COIHS is in default under
Section 9.c. above and whether or not ABHA elects to exercise its right to terminate this
Agreement under Section 9.e.(4) below, ABHA’s sole monetary remedy shall be a
claim for any unpaid Capitation Payments as identified in Exhibit C less previous
amounts paid and any claim(s) that COIHS has against ABHA. If previous amounts
paid to ABHA exceed the amount due to ABHA under this Section 9.d., ABHA shall
immediately pay any excess to COIHS upon written demand. If ABHA does not
immediately pay the excess, COIHS may recover the overpayment in accordance with
Section 7., above, (“Recovery of Overpayments”) and may pursue any other remedy
that may be available to it.
e. Termination
(1) ABHA agrees and understands that (i) this Agreement is part of a demonstration
project for integration of services in Central Oregon that is the subject of the
Effective: January 1, 2011
Exhibit D Page 100 of 221
Letter of Understanding dated ________ identified in Section III.B.7 of this
Agreement between the parties and DHS, and (ii) if DHS (or OHA), COIHS, or
Crook, Jefferson, and Deschutes Counties (referred to collectively as the
“participating counties”) determines, in consultation with the local Mental
Health Authorities, that the demonstration project is not achieving its goals, this
Agreement may be terminated by ABHA or COIHS upon 30 days written notice
to the other party. This paragraph is intended to carry out the intent of that
Letter of Understanding.
(2) COIHS Right to Terminate at its Discretion. At its sole discretion, COIHS may
terminate this Agreement:
(a) For its convenience upon 90 days’ prior written notice by COIHS to
ABHA; or
(b) Immediately upon notice if COIHS fails to receive payment from DHS
or other expenditure authority sufficient to allow COIHS, in the exercise
of its reasonable discretion, to continue to make payments under this
Agreement; or
(c) Immediately upon written notice if federal or state laws, regulations,
guidelines or CMS waiver terms are modified or interpreted in such a
way that DHS’ purchase of the Work or Work Products under this
Agreement is prohibited or DHS is prohibited from paying for such
Work or Work Products from the planned funding source; or
(d) Immediately upon written notice to ABHA if there is a threat to the
health, safety or welfare of any COIHS client, including any Medicaid
eligible individual, under its care.
(3) COIHS Right to Terminate for Cause. In addition to any other rights and
remedies COIHS may have under this Agreement, COIHS may terminate this
Agreement immediately upon written notice by COIHS to ABHA, or at such
later date as COIHS may establish in such notice, or upon expiration of the time
period and with such notice as provided in Section 10.e.(3)(b) or Section
10.e.(3)(c) below, upon the occurrence of any of the following events:
(a) ABHA is in default under Section 9.a.(1) because ABHA institutes or
has instituted against it insolvency, receivership or bankruptcy
proceedings, makes an assignment for the benefit of creditors, or ceases
doing business on a regular basis; or
(b) ABHA is in default under Section 9.a.(2) because ABHA no longer
holds a license or certificate that is required for it to perform Work under
the Agreement and ABHA has not obtained such license or certificate
within 14 calendar days after COIHS notice or such longer period as
COIHS may specify in such notice; or
Effective: January 1, 2011
Exhibit D Page 101 of 221
(c) ABHA is in default under Section 9.a.(3) because ABHA commits any
material breach or default of any covenant, warranty, obligation or
agreement under this Agreement, fails to perform the Work under this
Agreement within the time specified herein or any extension thereof, or
so fails to pursue the Work as to endanger ABHA's performance under
this Agreement in accordance with its terms, and such breach, default or
failure is not cured within 14 calendar days after COIHS notice, or such
longer period as COIHS may specify in such notice.
(4) Before terminating this Agreement under Section 9.e.((3), COIHS will:
(a) Provide ABHA with a written notice of its intent to terminate, the reason
for termination, and the opportunity for ABHA to call for a meeting of
senior executives of the parties, pursuant to Section III.D. of Exhibit A;
and
(b) After the meeting, give ABHA written notice of the decision affirming or
reversing the proposed termination of this Agreement and, for an
affirming decision, the effective date of the termination; and
(c) After a decision affirming termination, give OHP Members notice of the
termination and information on their options for receiving Medicaid
services following the effective date of the termination.
(d)
(5) ABHA's Right to Terminate for Cause. ABHA may terminate this Agreement
with such written notice to COIHS as provided in this Section 9.e.(5), or at such
later date as ABHA may establish in such notice, if COIHS is in default under
Section 9.c. because COIHS commits any material breach or default of any
covenant, warranty, or obligation under this Agreement, fails to perform its
commitments hereunder within the time specified or any extension thereof, and
COIHS fails to cure such failure within 30 calendar days after ABHA's notice or
such longer period as ABHA may specify in such notice.
(6) Mutual Termination. This Agreement may be terminated immediately upon
mutual written consent of the parties or at such other time as the parties may
agree in the written consent.
(7) Return of Property. Upon termination of this Agreement for any reason
whatsoever, ABHA shall immediately deliver to COIHS all of COIHS property
(including without limitation any Work Products for which COIHS has made
payment in whole or in part) that are in the possession or under the control of
ABHA in whatever stage of development and form of recordation such COIHS
property is expressed or embodied at that time. Upon receiving a notice of
termination of this Agreement, ABHA shall immediately cease all activities
under this Agreement, unless COIHS expressly directs otherwise in such notice
of termination. Upon COIHS request, ABHA shall surrender to anyone COIHS
Effective: January 1, 2011
Exhibit D Page 102 of 221
designates, all documents, research or objects or other tangible things needed to
complete the Work Products.
(8) In the event of termination of this Agreement, at the end of the term of this
Agreement if ABHA does not execute a new agreement or upon 90 day notice
that ABHA does not intend to renew this Agreement, the following provisions
shall apply to ensure continuity of the Work by ABHA. ABHA shall ensure:
(a) Continuation of services to OHP Members for the period in which a
Capitation Payment has been made, including Inpatient admissions up
until discharge;
(b) Orderly and reasonable transfer of OHP Member care in progress,
whether or not those OHP Members are hospitalized;
(c) Timely submission of information, reports and records, including
Encounter Data, required to be provided to COIHS during the term of
this Agreement;
(d) Timely payment of Valid Claims for services to OHP Members for dates
of service included in the Agreement year; and
(e) If ABHA continues to provide services to an OHP Member after the date
of termination, COIHS is only authorized to pay for services subject to
DMAP rules on a fee-for-service basis if the former OHP Member is
COIHS eligible and not covered under any other Mental Health
Organization. If ABHA chooses to provide services to a former OHP
Member who is no longer COIHS eligible, COIHS shall have no
responsibility to pay for such services.
(9) Upon termination, COIHS shall conduct an accounting of Capitation Payments
paid or payable and OHP Members enrolled during the month in which
termination is effective and shall be accomplished as follows:
(a) Mid-Month Termination: For a termination of this Agreement that
occurs during mid-month, the Capitation Payments for that month shall
be apportioned on a daily basis. ABHA shall be entitled to Capitation
Payments for the period of time prior to the date of termination, and
COIHS shall be entitled to a refund for the balance of the month.
(b) Responsibility for Capitated Payment/Claims: ABHA is responsible for
any and all claims from subcontractors or other Providers, including
Emergency Service Providers, for Covered Services provided prior to the
termination date.
(c) Notification of Outstanding COIHS Claims: ABHA shall promptly
notify COIHS of any outstanding claims for which COIHS may owe, or
be liable for, a fee for service payment (s), which are known to ABHA at
the time of termination or when such new claims incurred prior to
Effective: January 1, 2011
Exhibit D Page 103 of 221
termination are received. ABHA shall supply COIHS with all
information necessary for reimbursement of such claims.
(d) Responsibility to Complete Contractual Obligations: ABHA is
responsible for completing submission and corrections to Encounter Data
for Services received by OHP Members during the period of this
Agreement. ABHA is responsible for submitting financial and other
reports required during the period of this Agreement.
(e) Withholding: Pending Completion of Contractual Obligations: COIHS
shall withhold 20% of the ABHA’s last Capitation Payment until ABHA
has complied with all contractual obligations. COIHS determination of
completion of ABHA’s contractual obligations shall be no sooner than 6
months from the date of termination. Failure to complete said contractual
obligations within a reasonable time period shall result in a forfeiture of
the 20% withhold.
10. Limitation of Liabilities
NEITHER PARTY SHALL BE LIABLE FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES ARISING OUT
OF OR RELATED TO THIS AGREEMENT. NEITHER PARTY SHALL BE LIABLE FOR ANY DAMAGES OF
ANY SORT ARISING SOLELY FROM THE TERMINATION OF THIS AGREEMENT OF ANY PART HEREOF
IN ACCORDANCE WITH ITS TERMS. NEITHER PARTY SHALL BE LIABLE FOR ANY DAMAGES OF ANY
SORT ARISING FROM TERMINATION OF THIS AGREEMENT DUE TO LACK OF APPROPRIATIONS BY A
GOVERNING BODY OF A PARTY OR THE STATE OR FEDERAL GOVERNMENTS.
11. Insurance
ABHA shall maintain insurance as set forth in Exhibit F, which is attached hereto.
12. Access to Records and Facilities
ABHA shall maintain all financial records related to this Agreement in accordance with
generally accepted accounting principles. In addition, ABHA shall maintain any other records,
books, documents, papers, plans, records of shipment and payments and writings of ABHA,
whether in paper, electronic or other form, that are pertinent to this Agreement in such a
manner to clearly document ABHA’s performance. All financial records, other records, books,
documents, papers, plans, records of shipments and payments and writings of ABHA whether
in paper, electronic or other form, that are pertinent to this Agreement, are collectively referred
to as “Records.” ABHA acknowledges and agrees that COIHS, DHS, the Secretary of State's
Office, CMS, the Comptroller General of the United States, the Oregon Department of Justice
Medicaid Fraud Control Unit and their duly authorized representatives shall have access to all
Records to perform examinations and audits and make excerpts and transcripts. ABHA shall
retain and keep accessible all Records for the longer of:
a. Six (6) years following final payment and termination of this Agreement;
b. The period as may be required by applicable law, including the records retention
schedules set forth in OAR Chapter 166; or
Effective: January 1, 2011
Exhibit D Page 104 of 221
c. Until the conclusion of any audit, controversy or litigation arising out of or related to
this Agreement.
ABHA shall, upon request and without charge, provide a suitable work area and copying
capabilities to facilitate such a review or audit. This right also includes timely and reasonable
access to ABHA’s personnel and subcontractors for the purpose of interview and discussion
related to such documents. The rights of access in this subsection are not limited to the required
retention period, but shall last as long as the records are retained.
13. Information Privacy/Security/Access
If the Work performed under this Agreement requires ABHA or, when allowed, its
subcontractor(s), to have access to or use of any COIHS and/or applicable COIHS third-party
vendor computer system or other COIHS Information Asset for which COIHS imposes security
requirements, and COIHS grants ABHA access to such COIHS Information Assets or Network
and Information Systems, ABHA shall comply and require any subcontractor(s) to which such
access has been granted to comply with COIHS policies and procedures regarding such access
and OAR 407-014-0300 through OAR 407-014-0320, as such rules may be revised from time
to time. For purposes of this section, “Information Asset” and “Network and Information
System” have the meaning set forth in OAR 407-014-0305, as such rule may be revised from
time to time.
14. Force Majeure
a. Neither COIHS nor ABHA shall be held responsible for delay or default caused by fire,
riot, acts of God, power outage, government fiat, terrorist acts or other acts of political
sabotage, civil unrest, labor unrest or war, where such cause is beyond the reasonable
control of COIHS or ABHA, respectively, COIHS and ABHA shall, however, make all
reasonable efforts to remove or eliminate such a cause of delay or default and shall,
upon the cessation of the cause, diligently pursue performance of its obligations under
this Agreement.
b. If the rendering of Services or benefits under this Agreement is delayed or made
impractical due to any of the circumstances listed in Section 14.a., above, care may be
deferred until after resolution of those circumstances except in the following situations:
(1) Care is needed for Emergency Services;
(2) Care is needed for Urgent Care Services; or
(3) Care is needed where there is a potential for a serious adverse mental health or
medical consequence if Treatment or Diagnosis is delayed more than 30
calendar days.
c. If any of the circumstances listed in Section 14.a., above, disrupts normal execution of
ABHA’s duties under this Agreement, ABHA, in partnership with COIHS, shall notify
OHP Members in writing of the situation and direct OHP Members to bring serious
health care needs to ABHA’s attention.
Effective: January 1, 2011
Exhibit D Page 105 of 221
15. Resident Status of ABHA
As an ORS 190 intergovernmental entity, ABHA is domiciled in and registered to do business
in the State of Oregon.
16. Assignment of Agreement, Successors in Interest
a. ABHA shall not assign or transfer any of its interest in this Agreement without the prior
written consent of COIHS. Any such assignment or transfer, if approved, is subject to
such conditions and provisions as COIHS may deem necessary, including but not
limited to Exhibit L. No approval by COIHS of any assignment or transfer of interest
shall be deemed to create any obligation of COIHS in addition to those set forth in the
Agreement.
b. The provisions of this Agreement shall be binding upon and inure to the benefit of the
parties their respective successors and permitted assigns.
17. Subcontracting
ABHA shall notify COIHS of any subcontract(s) for any of the Work required by this
Agreement. In addition to any other provisions COIHS may require, ABHA shall include in
any permitted subcontract under this Agreement provisions to ensure that COIHS will receive
the benefit of subcontractor performance as if the Subcontractor were ABHA with respect to
Sections 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 15, 17, 18, and 19 of this Exhibit D. COIHS consent
to any subcontract shall not relieve ABHA of any of its duties or obligations under this
Agreement. In addition to the requirements in this section, ABHA shall comply with all of the
“Additional Subcontracting Requirements” in Exhibit P.
18. No Third Party Beneficiaries
COIHS and ABHA are the only parties to this Agreement and are the only parties entitled to
enforce its terms. Nothing in this Agreement gives, is intended to give, or shall be construed to
give or provide any benefit or right, whether directly, indirectly or otherwise, to third persons
that are greater than the rights and benefits enjoyed by the general public unless such third
persons are individually identified by name herein and expressly described as intended
beneficiaries of the terms of this Agreement.
19. Amendments; Waiver; Consent
a. COIHS may amend this Agreement to the extent provided herein, or in any solicitation
document, from which this Agreement arose, and to the extent required by DHS or
permitted by applicable statutes and administrative rules. No amendment, waiver, or
other consent under this Agreement shall bind either party unless it is in writing and
signed by the party to be bound. Such amendment, waiver, or consent shall be effective
only in the specific instance and for the specific purpose given. The failure of either
party to enforce any provision of this Agreement shall not constitute a waiver by that
party of that or any other provisions.
Effective: January 1, 2011
Exhibit D Page 106 of 221
b. COIHS may provide ABHA with an amendment if COIHS is required to amend this
Agreement due to changes in its contract with DHS, or federal or State statute or
regulations, or due to changes in Covered Services and Capitation Payments under ORS
414.735, and if failure to amend this Agreement to execute those changes in the time
and manner proposed in the amendment may place COIHS at risk of non-compliance
with its contract with DHS, or federal or State statute or regulations or the requirements
of the Legislature or Legislative Emergency Board. In addition, COIHS may, at COIHS
sole discretion, amend the Agreement to address budgetary constraints, including those
arising from changes in funding, appropriations, limitations, allotments, or other
expenditure authority limitations provided in Section 6 of this Exhibit D.
20. Severability
If any term or provision of this Agreement is declared by a court of competent jurisdiction to be
illegal or in conflict with any law, the validity of the remaining terms and provisions shall not
be affected, and the rights and obligations of the parties shall be construed and enforced as if
this Agreement did not contain the particular term or provision held to be invalid.
21. Survival
Sections 1, 4, 8, 9, 10, 12, 13, 14, 17, 19, and 22 of this Exhibit D shall survive Agreement
expiration or termination, as well as those provisions of this Agreement that by their context are
meant to survive. Agreement expiration or termination shall not extinguish or prejudice
COIHS right to enforce this Agreement with respect to any default by ABHA that has not been
cured.
22. Notices
a. Except as otherwise expressly provided in this Agreement, any communications
between the parties hereto or notices to be given hereunder shall be given in writing by
personal delivery, facsimile, email or mailing the same, postage prepaid, to ABHA or
COIHS at the addresses or numbers set forth in this Agreement, or to such other
addresses or numbers as either party may indicate pursuant to this Agreement. Any
communication or notice so addressed and mailed by regular mail shall be deemed
received and effective five (5) days after the date of mailing. Any communication or
notice delivered by facsimile or email shall be deemed received and effective on the day
the transmitting machine generates receipt of the transmission, if transmission was
during normal business hours, or on the next business day, if transmission was outside
normal business hours of the recipient. Any communication or notice by personal
delivery shall be effective when actually delivered to the addressee.
COIHS: Entity Name Central Oregon Individual Health
Solutions, Inc.
Contact Name (optional) Dan Stevens
Street Address 2965 NE Conners Avenue
City, State, Zip Bend, OR 97701
Telephone 541-385-5315
Facsimile: 541-270-1428
Effective: January 1, 2011
Exhibit D Page 107 of 221
Email dstevens@pacificsource.com
ABHA: Entity Name ___________________
Contact Name (optional) ___________________
Street Address ___________________
City, State Zip ___________________
Telephone: ___________________
Facsimile: ___________________
Email address ___________________
OHP Member: To the latest address provided for the OHP Member on an
address list, enrollment or change of address form actually
received by ABHA.
23. Construction
This Agreement is the product of extensive negotiations between COIHS and ABHA. The
provisions of this Agreement are to be interpreted and their legal effects determined as a whole.
A court interpreting this Agreement shall give a reasonable, lawful and effective meaning to
this Agreement to the extent possible. The rule of construction that ambiguities in a written
agreement are to be construed against the party preparing or drafting the agreement shall not be
applicable to the interpretation of this Agreement.
24. Headings and Captions
The headings and captions to sections of this Agreement have been inserted for identification
and reference purposes only and shall not be used to construe the meaning or to interpret this
Agreement.
25. Merger Clause
This Agreement constitutes the entire agreement between the parties on the subject matter
hereof. There are no understandings, agreements, or representations, oral or written, not
specified herein regarding this Agreement.
26. Counterparts
This Agreement and any subsequent amendments may be executed in several counterparts, all
of which when taken together shall constitute one agreement binding on all parties,
notwithstanding that all parties are not signatories to the same counterpart. Each copy of this
Agreement and any amendments so executed shall constitute an original.
27. Equal Access
Effective: January 1, 2011
Exhibit D Page 108 of 221
ABHA shall provide equal access to Covered Services for both male and female members
under 18 years of age, including access to appropriate facilities, services and treatment, to
achieve the policy in ORS 417.270.
Effective: January 1, 2011
Exhibit E Page 109 of 221
Exhibit E - Required Federal Terms and Conditions
Unless exempt under 45CFR Part 87 for Faith-Based Organizations (Federal Register, July 16, 2004,
Volume 69, #136), or other federal provisions, ABHA shall comply and, as indicated, cause all
subcontractors to comply with the following federal requirements to the extent that they are applicable to this
Agreement, to ABHA, or to the Work, or to any combination of the foregoing. For purposes of this
Agreement, all references to federal and state laws are references to federal and state laws as they may be
amended from time to time.
1. Miscellaneous Federal Provisions
ABHA shall comply and cause all subcontractors to comply with all federal laws, regulations, and
executive orders applicable to this Agreement or to the delivery of Work. Without limiting the
generality of the foregoing, ABHA expressly agrees to comply and cause all subcontractors to
comply with the following laws, regulations and executive orders to the extent they are applicable to
this Agreement: (a) Title VI and VII of the Civil Rights Act of 1964, (b), 45 CFR Part 84 which
implements , Title V, Sections 503 and 504 of the Rehabilitation Act of 1973, (c) the Americans with
Disabilities Act of 1990, (d) Executive Order 11246, (e) the Health Insurance Portability and
Accountability Act of 1996, (f) the Age Discrimination in Employment Act of 1967, as amended, and
the Age Discrimination Act of 1975, (g) the Vietnam Era Veterans' Readjustment Assistance Act of
1974, (h) all regulations and administrative rules established pursuant to the foregoing laws, (i) all
other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations,
and (j) all federal law governing operation of Community Mental Health Programs, including without
limitation, all federal laws requiring reporting of Client Abuse. These laws, regulations and executive
orders are incorporated by reference herein to the extent that they are applicable to this Agreement
and required by law to be so incorporated. No federal funds may be used to provide Work in
violation of 42 USC 14402.
2. Equal Employment Opportunity
If this Agreement, including amendments, is for more than $10,000, then ABHA shall comply and
cause all subcontractors to comply with Executive Order 11246, entitled "Equal Employment
Opportunity," as amended by Executive Order 11375, and as supplemented in Department of Labor
regulations (41 CFR Part 60).
3. Clean Air, Clean Water, EPA Regulations
If this Agreement, including amendments, exceeds $100,000 then ABHA shall comply and cause all
subcontractors to comply with all applicable standards, orders, or requirements issued under Section
306 of the Clean Air Act (42 U.S.C. 7606), the Federal Water Pollution Control Act as amended
(commonly known as the Clean Water Act) (33 U.S.C. 1251 to 1387), specifically including, but not
limited to Section 508 (33 U.S.C. 1368). Executive Order 11738, and Environmental Protection
Agency regulations (2 CFR Part 1532), which prohibit the use under non-exempt Federal contracts,
grants or loans of facilities included on the EPA List of Violating Facilities. Violations shall be
reported to COIHS, DHHS and the appropriate Regional Office of the Environmental Protection
Agency. ABHA shall include and cause all subcontractors to include in all contracts with
subcontractors receiving more than $100,000, language requiring the subcontractor to comply with
the federal laws identified in this section.
4. Energy Efficiency
Effective: January 1, 2011
Exhibit E Page 110 of 221
ABHA shall comply and cause all subcontractors to comply with applicable mandatory standards and
policies relating to energy efficiency that are contained in the Oregon energy conservation plan
issued in compliance with the Energy Policy and Conservation Act, 42 U.S.C. 6201 et seq. (Pub. L.
94-163).
5. Truth in Lobbying
ABHA certifies, to the best of the ABHA's knowledge and belief that:
a. No federal appropriated funds have been paid or will be paid, by or on behalf of ABHA, to
any person for influencing or attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any federal contract, the making of any federal
grant, the making of any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal contract, grant,
loan or cooperative agreement.
b. If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this federal contract, grant, loan or cooperative agreement, the
ABHA shall complete and submit Standard Form LLL, "Disclosure Form to Report
Lobbying" in accordance with its instructions.
c. The ABHA 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 and subcontractors
shall certify and disclose accordingly.
d. This certification is a material representation of fact upon which reliance was placed when
this Agreement was made or entered into. Submission of this certification is a prerequisite for
making or entering into this Agreement imposed by Section 1352, Title 31, of the U.S. Code.
Any person who fails to file the required certification shall be subject to a civil penalty of not
less than $10,000 and not more than $100,000 for each such failure.
6. Health Insurance Portability and Accountability Act (HIPAA)
If the Work funded in whole or in part with financial assistance provided under this Agreement is
covered by the Health Insurance Portability and Accountability Act or the federal regulations
implementing the Act (collectively referred to as HIPAA), ABHA agrees to deliver the Work in
compliance with HIPAA. Without limiting the generality of the foregoing, Work for treatment,
payment, health care operation or any other purpose permitted by HIPAA provided under this
Agreement is covered by HIPAA. ABHA shall comply and cause all Subcontractors to comply with
the following:
a. Privacy and Security of Individually Identifiable Health Information. Individually
Identifiable Health Information about specific individuals is confidential. Individually
Identifiable Health Information relating to specific individuals may be exchanged between
ABHA and COIHS for purposes directly related to the provision of services to Clients which
are funded in whole or in part under this Agreement. However, ABHA shall not use or
disclose any Individually Identifiable Health Information about specific individuals in a
Effective: January 1, 2011
Exhibit E Page 111 of 221
manner that would violate DHS Privacy Rules, OAR 407-014-0000 et. seq., or DHS Notice of
Privacy Practices, if done by COIHS or DHS. A copy of the most recent DHS Notice of
Privacy Practices is posted on the DHS web site at
http://www.dhs.state.or.us/policy/admin/infosecuritylist.htm, or may be obtained from DHS.
b. Consultation and Testing. If ABHA reasonably believes that the ABHA's or COIHS’s data
transactions system or other application of HIPAA privacy or security compliance policy may
result in a violation of HIPAA requirements, ABHA shall promptly consult the COIHS
HIPAA officer. ABHA or COIHS may initiate a request for testing of HIPAA transaction
requirements, subject to available resources and COIHS testing schedule.
7. Resource Conservation and Recovery
ABHA shall comply and cause all subcontractors to comply with all mandatory standards and
policies that relate to resource conservation and recovery pursuant to the Resource Conservation and
Recovery Act (codified at 42 USC 6901 et. seq.). Section 6002 of that Act (codified at 42 USC
6962) requires that preference be given in procurement programs to the purchase of specific products
containing recycled materials identified in guidelines developed by the Environmental Protection
Agency. Current guidelines are set forth in 40 CFR Part 247.
8. Audits
ABHA shall comply and, if applicable, cause a subcontractor to comply, with the applicable audit
requirements and responsibilities set forth in the Office of Management and Budget Circular A-133
entitled "Audits of States, Local Governments and Non-Profit Organizations."
9. Debarment and Suspension
ABHA shall not permit any person or entity to be a subcontractor if the person or entity is listed on
the non-procurement portion of the General Service Administration's "List of Parties Excluded from
Federal Procurement or Nonprocurement Programs" in accordance with Executive Orders No. 12549
and No. 12689, "Debarment and Suspension". (See 2 CFR Part 180). This list contains the names of
parties debarred, suspended, or otherwise excluded by agencies, and ABHA declared ineligible under
statutory authority other than Executive Order No. 12549. Subcontractors with awards that exceed
the simplified acquisition threshold shall provide the required certification regarding their exclusion
status and that of their principals prior to award.
10. Drug-Free Workplace
ABHA shall comply and cause all subcontractors to comply with the following provisions to
maintain a drug-free workplace: (i) ABHA certifies that it will provide a drug-free workplace by
publishing a statement notifying its employees that the unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance, except as may be present in lawfully
prescribed or over-the-counter medications, is prohibited in ABHA's workplace or while providing
services to DHS clients. ABHA's notice shall specify the actions that will be taken by ABHA against
its employees for violation of such prohibitions; (ii) Establish a drug-free awareness program to
inform its employees about: The dangers of drug abuse in the workplace, ABHA's policy of
maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee
assistance programs, and the penalties that may be imposed upon employees for drug abuse
violations; (iii) Provide each employee to be engaged in the performance of services under this
Effective: January 1, 2011
Exhibit E Page 112 of 221
Agreement a copy of the statement mentioned in Paragraph (i) above; (iv) Notify each employee in
the statement required by Paragraph (i) above that, as a condition of employment to Provide Services
under this Agreement, the employee will: abide by the terms of the statement, and notify the
employer of any criminal drug statute conviction for a violation occurring in the workplace no later
than five (5) days after such conviction; (v) Notify COIHS within ten (10) days after receiving notice
under Paragraph (iv) above, from an employee or otherwise receiving actual notice of such
conviction; (vi) Impose a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program by any employee who is so convicted as required by Section
5154 of the Drug-Free Workplace Act of 1988; (vii) Make a good-faith effort to continue a drug-free
workplace through implementation of Paragraphs (i) through (vi) above; (viii) Require any
subcontractor to comply with Paragraphs (i) through (vii) above; 10(ix) Neither ABHA, or any of
ABHA's employees, officers, agents or subcontractors may Provide any Service required under this
Agreement while under the influence of drugs. For purposes of this provision, "under the influence"
means: observed abnormal behavior or impairments in mental or physical performance leading a
reasonable person to believe the ABHA or ABHA's employee, officer, agent or subcontractor has
used a controlled substance, prescription or non-prescription medication that impairs the ABHA or
ABHA's employee, officer, agent or subcontractor's performance of essential job function or creates a
direct threat to COIHS clients or others. Examples of abnormal behavior include, but are not limited
to: hallucinations, paranoia or violent outbursts. Examples of impairments in physical or mental
performance include, but are not limited to: slurred speech, difficulty walking or performing job
activities; and (x) Violation of any provision of this subsection may result in termination of this
Agreement.
11. Pro-Children Act
ABHA shall comply and cause all subcontractors to comply with the Pro-Children Act of 1994
(codified at 20 USC Section 6081 et. seq.).
12. Additional Medicaid and SCHIP Requirements
ABHA shall comply with all applicable federal and state laws and regulations pertaining to the
provision of OHP Services under the Medicaid Act, Title XIX, 42 USC Section 1396 et. seq., and
SCHIP benefits established by Title XXI of the Social Security Act, including without limitation:
a. Keep such records as are necessary to fully disclose the extent of the services provided to
individuals receiving OHP assistance and shall furnish such information to any state or federal
agency responsible for administering the OHP program regarding any payments claimed by
such person or institution for providing OHP Services as the state or federal agency may from
time to time request. 42 USC Section 1396a(a)(27); 42 CFR 431.107(b)(1) & (2); and 42
CFR 457.950(a)(3).
b. Comply with all disclosure requirements of 42 CFR 1002.3(a); 42 CFR 455 Subpart (B); and
42 CFR 457.900(a)(2)..
c. Maintain written notices and procedures respecting advance directives in compliance with 42
USC Section 1396(a)(57) and (w), 42 CFR 431.107(b)(4), and 42 CFR 489 Subpart I.
d. Certify when submitting any claim for the provision of OHP Services that the information
submitted is true, accurate and complete. ABHA shall acknowledge ABHA's understanding
that payment of the claim will be from federal and state funds and that any falsification or
concealment of a material fact may be prosecuted under federal and state laws.
Effective: January 1, 2011
Exhibit E Page 113 of 221
e. Entities receiving $5 million or more annually (under this Agreement and any other OHP
contract) for furnishing Medicaid health care items or services shall, as a condition of
receiving such payments, adopt written fraud, waste and abuse policies and procedures and
inform employees, ABHAs and agents about the policies and procedures in compliance with
Section 6032 of the Deficit Reduction Act of 2005, 42 USC § 1396a(a)(68).
13. Agency-based Voter Registration
If applicable, ABHA shall comply with the Agency-based Voter Registration sections of the National
Voter Registration Act of 1993 that require voter registration opportunities be offered where an
individual may apply for or receive an application for public assistance.
14. Clinical Laboratory Improvements
ABHA shall and shall ensure that any laboratories used by ABHA shall comply with the Clinical
Laboratory Improvement Amendments (CLIA 1988) 42 CFR Part 493 Laboratory Requirements and
ORS 438 Clinical Laboratories, which require that all laboratory testing sites providing Services
under this Agreement shall have either a Clinical Laboratory Improvement Amendments (CLIA)
certificate of waiver or a certificate of registration along with a CLIA identification number. Those
laboratories with certificates of waiver will provide only the eight types of tests permitted under the
terms of their waiver. Laboratories with certificates of registration may perform a full range of
laboratory tests.
15. Advance Directives
ABHA shall comply with 42 CFR Part 422.128 for maintaining written policies and procedures for
advance directives. This includes compliance with 42 CFR 489, Subpart I “Advance Directives” and
OAR 410-120-1380, which establishes, among other requirements the requirements for compliance
with Section 4751 of the Omnibus Budget Reconciliation Act of 1991 (OBRA) and ORS 127.649,
Patient Self-Determination Act. ABHA shall maintain written policies and procedures concerning
advance directives with respect to all adult OHP Members receiving medical care by ABHA. ABHA
shall provide adult OHP Members with written information on advance directive policies and include
a description of Oregon law. The written information provided by ABHA must reflect changes in
Oregon law as soon as possible, but no later than 90 days after the effective date of any change to
Oregon law. ABHA must also provide written information to adult OHP Members with respect to
the following:
a. Their rights under Oregon law; and
b. ABHA’s policies respecting the implementation of those rights, including a statement of any
limitation regarding the implementation of advance directives as a matter of conscience.
c. ABHA must inform OHP Members that complaints concerning noncompliance with the
advance directive requirements may be filed with COIHS .
16. Office of Minority, Women and Emerging Small Businesses
If ABHA lets any subcontracts, ABHA shall take affirmative steps to: include qualified small and
minority and women’s businesses on solicitation lists, assure that small and minority and women’s
businesses are solicited whenever they are potential sources, divide total requirements into smaller
Effective: January 1, 2011
Exhibit E Page 114 of 221
tasks or quantities when economically feasible so as to permit maximum small and minority and
women’s business participation, establish delivery schedules when requirements permit which will
encourage participation by small and minority and women’s businesses, and use the Services and
assistance of the Small Business Administration, the Office of Minority Business Enterprise of the
Department of Commerce and the Community Services Administration as required.
17. Practitioner Incentive Plans
ABHA may operate a Practitioner Incentive Plan only if no specific payment is made directly or
indirectly under the plan to a Provider as inducement to reduce or limit Medically Appropriate
Covered Services provided to an OHP Member. ABHA shall comply with all requirements of
Exhibit M, Practitioner Incentive Plans, to ensure compliance with Sections 4204 (a) and 4731 of the
Omnibus Budget Reconciliation Act of 1990 that concern physician incentive plans.
18. Risk HMO
If ABHA is a Risk HMO and is sanctioned by CMS under 42 CFR 438.730, payments provided for
under this Agreement will be denied for OHP Members who enroll after the imposition of the
sanction, as set forth under 42 CFR 438.726.
19. Conflict of Interest Safeguards
a. ABHA shall not recruit, promise future employment, or hire any COIHS employee (or their
relative or member of their household) who has participated personally and substantially in
the procurement or administration of this Agreement as a COIHS employee.
b. ABHA shall not offer to any COIHS employee (or any relative or member of their household)
any gift or gifts with an aggregate value in excess of $50 during a calendar year or any gift of
payment of expenses for entertainment. “Gift” for this purpose has the meaning defined in
ORS 244.020(6) and OAR 199-005-0001 to 199-005-0035.
c. ABHA shall not retain a former COIHS employee to make any communication with or
appearance before COIHS on behalf of ABHA in connection with this Agreement if that
person participated personally and substantially in the procurement or administration of this
Agreement as a COIHS employee.
d. If a former COIHS employee authorized or had a significant role in this Agreement, ABHA
shall not hire such a person in a position having a direct, beneficial, financial interest in this
Agreement during the two year period following that person’s termination from COIHS.
e. ABHA shall develop appropriate policies and procedures to avoid actual or potential conflict
of interest involving OHP Members, COIHS employees, and sub-contractors. These policies
and procedures shall include safeguards:
(1) against the ABHA’s disclosure of applications, bids, proposal information, or source
selection information; and
(2) requiring the ABHA to:
i. promptly report any contact with an applicant, bidder or offeror in writing to
COIHS; and
Effective: January 1, 2011
Exhibit E Page 115 of 221
ii. reject the possibility of possible employment; or disqualify itself from further
personal and substantial participation in the procurement if ABHA contacts or
is contacted by a person who is an applicant, bidder or offeror in a procurement
involving federal funds regarding possible employment for the ABHA.
f. The provisions of this section on Conflict of Interest are intended to be construed to assure the
integrity of the procurement and administration of this Agreement. For purposes of this
Section:
(1) “Agreement” includes any similar contract between ABHA and COIHS for a previous
term.
(2) ABHA shall apply the definitions in the State Public Ethics Law, ORS 244.020, for
“actual conflict of interest”, “potential conflict of interest”, “relative” and “member of
household”.
(3) “ABHA” for purposes of this section includes all ABHA’s affiliates, assignees,
subsidiaries, parent companies, successors and transferees, and persons under common
control with the ABHA; any officers, directors, partners, agents and employees of
such person; and all others acting or claiming to act on their behalf or in concert with
them.
(4) “Participates” means actions of a COIHS employee, through decision, approval,
disapproval, recommendation, the rendering of advice, investigation or otherwise in
connection with the Agreement.
(5) “Personally and substantially” has the meaning set forth in 5 CFR 2635.402(b)(4).
20. Non-Discrimination
ABHA shall comply with all Federal and State laws and regulations including Title VI of the Civil
Rights Act of 1964, Title IX of the Education Amendments of 1972 (regarding education programs
and activities) the Age Discrimination Act of 1975, the Rehabilitation Act of 1973, the Americans
with Disabilities Act (ADA) of 1990, and all amendments to those acts and all regulations
promulgated there under. ABHA shall also comply with all applicable requirements of state civil
rights and rehabilitation statutes and rules.
21. Federal Grant Requirements
The federal Medicaid rules establish that DHS is a recipient of federal financial assistance, and
therefore is subject to federal grant requirements pursuant to 42 CFR 430.2(b). To the extent
applicable to COIHS and/or ABHA or to the extent COIHS or ABHA need to supply information or
comply with procedures to permit DHS to satisfy its obligations federal grant obligations or both,
ABHA must comply with the following parts of 45 CFR:
a. Part 74, including Appendix A (uniform federal grant administration requirements);
b. Part 80 (nondiscrimination under Title VI of the Civil Rights Act);
c. Part 84 (nondiscrimination on the basis of handicap);
Effective: January 1, 2011
Exhibit E Page 116 of 221
d. Part 91 (nondiscrimination on the basis of age);
e. Part 95 (Medicaid and SCHIP federal grant administration requirements); and
f. ABHA shall not expend, and ABHA shall include a provision in any Subcontract that its
subcontractor shall not expend, any of the funds paid under this Agreement for roads, bridges,
stadiums, or any other item or service not covered under the OHP.
22. Provider’s Opinion
OHP Members are entitled to the full range of their health care Provider’s opinions and counsel about
the availability of Medically Appropriate services under the OHP.
ABHA shall not prohibit or otherwise restrict a Health Care Professional from advising an OHP
Member who is a patient of that professional about the health status of the OHP Member or treatment
for the OHP Member’s condition or disease, regardless of whether benefits for such care or treatment
are provided under the Plus or Standard Benefit Package of Covered Services or if a co-payment may
be required, if the professional is acting within the lawful scope of practice.
Effective: January 1, 2011
Exhibit F Page 117 of 221
Exhibit F – Insurance Requirements
Required Insurance: ABHA shall obtain at ABHA’s expense the insurance specified in this Exhibit F, prior to
performing under this Agreement and shall maintain it in full force and at its own expense throughout the
duration of this Agreement and any warranty period. ABHA shall obtain the following insurance from
insurance companies or entities that are authorized to transact the business of insurance and issue coverage in
the State of Oregon and that are acceptable to COIHS.
1. Workers’ Compensation: All employers, including ABHA, that employ subject workers, as defined in
ORS 656.027, shall comply with ORS 656.017, and shall provide worker’s compensation insurance
coverage for those workers, unless they meet the requirement for an exemption under ORS 656.126(2).
ABHA shall require and ensure that each of its Subcontractors complies with these requirements.
2. Professional Liability: Covers any damages caused by an error, omission or any negligent acts related
to the services to be provided under this Agreement. ABHA shall provide proof of insurance with not
less than the following limits:
From January 1, 2011 through June 30, 2011
A combined single limit per occurrence of not less than 1,700,000, and
An aggregate limit for all claims of not less than 3,700,000.
From July 1, 2011 through December 31, 2011
A combined single limit per occurrence of not less than 1,800,000, and
An aggregate limit for all claims of not less than 3,900,000.
3. Commercial General Liability: Covers bodily injury, death and property damage in a form and with
coverage’s that are satisfactory to the State. This insurance shall include personal injury liability,
products and completed operations. Coverage shall be written on an occurrence basis. ABHA shall
provide proof of insurance with not less than the following limits:
From January 1, 2011 through June 30, 2011
A combined single limit per occurrence of not less than 1,700,000, and
An aggregate limit for all claims of not less than 3,700,000.
From July 1, 2011 through December 31, 2011
A combined single limit per occurrence of not less than 1,800,000, and
An aggregate limit for all claims of not less than 3,900,000.
4. Automobile Liability: Covers all owned, non-owned, or hired vehicles, this coverage may be written in
combination with the Commercial General Liability Insurance (with separate limits for “Commercial
General Liability” and “Automobile Liability”). ABHA shall provide proof of insurance with no less
than the following limits:
From January 1, 2011 through June 30, 2011
A combined single limit per occurrence of not less than 1,600,000, and
An aggregate limit for all claims of not less than 3,200,000.
Effective: January 1, 2011
Exhibit F Page 118 of 221
From July 1, 2011 through December 31, 2011
A combined single limit per occurrence of not less than 1,700,000, and
An aggregate limit for all claims of not less than 3,900,000.
5. Additional Insured: The Commercial General Liability insurance and Automobile Liability insurance
required under this Agreement shall include COIHS and the State of Oregon, its officers, employees and
agents as Additional Insureds but only with respect to ABHA's activities to be performed under this
Agreement. Coverage shall be primary and non-contributory with any other insurance and self-
insurance.
6. Notice of Cancellation or Change: There shall be no cancellation, material change, potential
exhaustion of aggregate limits or non–renewal of insurance coverage(s) without sixty (60) days’ prior
written notice from ABHA or its insurer(s) to COIHS. Any failure to comply with the reporting
provisions of this clause shall constitute a material breach of Agreement and shall be grounds for
immediate termination of this Agreement by COIHS.
7. Proof of Insurance: ABHA shall provide to COIHS information requested in Part V “ABHA Data and
Certification” of the Contract Document, for all required insurance before delivering any goods and
performing any services required under this Agreement. ABHA shall pay for all deductibles, self
insured retentions, and self insurance, if any.
8. “Tail” Coverage: If any of the required liability insurance is on a “claims made” basis, ABHA shall
either maintain either “tail” coverage or continuous “claims made” liability coverage, provided the
effective date of the continuous “claims made” coverage is on or before the effective date of this
Agreement, for a minimum of 24 months following the later of (i) ABHA’s completion and COIHS’
acceptance of all Services required under this Agreement, or, (ii) The expiration of all warranty periods
provided under this Agreement. Notwithstanding the foregoing 24-month requirement, if ABHA elects
to maintain “tail” coverage and if the maximum time period “tail” coverage reasonably available in the
marketplace is less than the 24-month period described above, then ABHA shall maintain “tail”
coverage for the maximum time period that “tail” coverage is reasonably available in the marketplace
for the coverage required under this Agreement. ABHA shall provide to COIHS, upon COIHS’ request,
certification of the coverage required under this Section 8.
9. Self-insurance: ABHA may fulfill its insurance obligations herein through a program of self insurance,
provided that ABHA’s self insurance program complies with all applicable laws, and provides insurance
coverage equivalent in both type and level of coverage to that required in this Exhibit F.
Notwithstanding Section 7 of this Exhibit F, ABHA shall furnish an acceptable insurance certificate to
COIHS for any insurance coverage required by this Agreement that is fulfilled through self-insurance.
Effective: January 1, 2011
Exhibit G Page 119 of 221
Exhibit G – Solvency Plan and Financial Reporting
ABHA shall maintain sound financial management procedures, maintain protections against
insolvency commensurate with the number of OHP Members and level of risk assumed, and
generate periodic financial reports for submission to COIHS (OAR 410-141-0340). Financial
management, solvency protection, and reporting shall occur as specified below.
1. ABHA agrees to include all of its OHP financial activities under Corporate Activity when
completing Reports G.2 through G.5. Any changes to the reporting of Corporate Activity
shall be approved by COIHS in writing before implementation.
2. ABHA shall protect itself against catastrophic and unexpected expenses related to
Covered Services by either self-insuring or by obtaining stop-loss protection from a
private insurer in an amount sufficient to cover estimated risk for the duration of this
Agreement. ABHA shall provide proof of such coverage to COIHS within 15 days after
the effective date of this Agreement.
3. Restricted Reserve Fund
ABHA shall maintain a Restricted Reserve Fund balance no less than $250,000 and
provide evidence of the required restricted reserve account balance to COIHS within 45
calendar days after the end of each calendar quarter as outlined below. ABHA shall
identify where and by whom the restricted reserve account is held.
a. If ABHA subcontracts any work to be performed under this Agreement using a
subcapitated reimbursement arrangement, ABHA may choose to require its
subcontractor to maintain a Restricted Reserve Fund for the subcontractor’s
portion of the risk assumed or may maintain a Restricted Reserve Fund for all risk
assumed under this Agreement. Regardless of the choice made, ABHA shall
assure that the combined total Restricted Reserve Fund balance meets the
requirements of this Agreement.
b. If the Restricted Reserve Fund is held in a combined account or pool with other
entities, ABHA, and its subcontractors as applicable, shall provide a statement
from the pool or account manager that the Restricted Reserve Fund is available to
ABHA, or its subcontractors as applicable, and has not been obligated elsewhere.
c. If ABHA must use its Restricted Reserve Fund to finance Covered Services,
ABHA shall provide advance written notice to COIHS of the amount to be
withdrawn, the reason for withdrawal, when and how the Restricted Reserve Fund
will be replenished, and steps to be taken to avoid the need for future Restricted
Reserve Fund withdrawals.
d. ABHA shall provide COIHS access to its Restricted Reserve Fund if insolvency
occurs.
Effective: January 1, 2011
Exhibit G Page 120 of 221
e. ABHA shall have written policies and procedures to ensure that, if insolvency
occurs, OHP Members and related Clinical Records are transitioned with minimal
disruption.
4. ABHA shall provide TPR collection information, using Report G.2, Current OHP
Members with Third Party Resources (Quarterly Report), on a quarterly basis within 50
calendar days after the end of each calendar quarter. ABHA shall make reasonable efforts
to identify and pursue such Third Party Resource without regard to any Capitation
Payments. ABHA shall keep records of such efforts, successful or unsuccessful, to
ensure accuracy of such reports and make records available for audit and review upon
request. ABHA shall report all TPR including amounts recovered by capitated
subcontract Providers.
5. ABHA shall provide financial information, using Report G.3, Quarterly Balance Sheet,
within 50 calendar days after the end of each calendar quarter. ABHA shall have systems
that capture, compile, and evaluate information and data concerning financial operations
including, but not limited to, the determination of future budget requirements and for
determining, managing and accounting for claims payable and “Incurred But Not
Reported” expenses.
6. ABHA shall provide financial information, using Reports G.4, ABHA’s Quarterly
Statement of Revenue and Expenses, G.4A, Health Care Expenses By Service Type, and
G.4B, Prevention/Education/Outreach Activities, on a quarterly basis within 60 calendar
days after the end of each calendar quarter.
In addition to the quarterly reports, ABHA shall provide a Report G.4 based on ABHA’s
fiscal year which shall include a detailed description of how a net loss was covered or
how a net income will be used during the next fiscal year.
7. ABHA shall provide financial information, using Report G.5, Fiscal Year Cash Flow
Analysis for Corporate Activity within 80 calendar days after the end of ABHA’s fiscal
year.
8. ABHA shall submit an Annual Audited Financial Statement to COIHS within 170 days
after the end of the ABHA fiscal year. The audited financial statement shall be prepared
by an independent accounting firm. In conducting the audit of the financial statements,
the auditor will apply sufficient procedures to conclude that, in all material respects:
a. the assumptions and methods used in determining loss reserves, actuarial
liabilities, or other related accounting items are appropriate in the circumstances,
and
b. the information on the ABHA's G.3, G.4, G.4A, G.4B and G.5 reports is
accurately included within the amounts presented in the ABHA's financial
statements and footnote disclosures.
Effective: January 1, 2011
Exhibit G Page 121 of 221
9. ABHA shall notify COIHS of any significant change to the information provided in the
quarterly financial reports. If the change requires restatement of a prior quarterly
financial report, ABHA shall amend the report and submit to COIHS within 20 working
days of the date the change is identified.
10. ABHA shall supply COIHS with a spreadsheet, or other mutually agreed upon format,
containing the quarterly financial reports either electronically or by mailing a 3.5"
computer disk, CD, spreadsheet, hard copy or facsimile. ABHA shall send these reports
to COIHS .
11. If ABHA has questions about these reports, ABHA may call the COIHS.
12. If ABHA wants these reports electronically, on a 3.5" computer disk, CD, spreadsheet,
hard copy or facsimile, ABHA may call (503) 947-5522.
Effective: January 1, 2011
Exhibit G – Attachment 1 – Report G.2 Page 122 of 221
Exhibit G – Attachment 1
Report G.2: Current OHP Members with Third Party Resources (Quarterly Report)
ABHA
Contract Year:
Report Period:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
Report due within 45 calendar days after the end of each calendar quarter.
Instructions:
1. Provide TPR information for Covered Services, including all TPR recovered by sub-
capitated Providers.
2. Separate amounts collected by Medicare, other insurance collections, and tort and estate
collections, and Capitation rate category.
3. If the accounts receivable system cannot capture collections by Capitation rate category,
do the following:
a. Record total collections by Medicare, other insurance, and tort and estate
recoveries.
b. Keep detailed records of all collections by OHP Member name, prime number
and Third Party Resource.
c. Provide a written statement with the report indicating when Third Party Resource
collection information will be available by Capitation rate category.
Capitation Rate Category Medicare
Collections
Other
Insurance
Collections
Tort and
Estate
Collections
Total
Collections
1. TANF
2. General Assistance
3. PLM Adults under 100% FPL
4. PLM Adults over 100% FPL
5. SCHIP Children Aged 0 - 1
6. PLM Children Aged 0 – 1
7. PLM or SCHIP Children
Aged 1- 5
Effective: January 1, 2011
Exhibit G – Attachment 1 – Report G.2 Page 123 of 221
Capitation Rate Category Medicare
Collections
Other
Insurance
Collections
Tort and
Estate
Collections
Total
Collections
8. PLM or SCHIP Children
Aged 6 - 18
9. OHP Families
10. OHP Adults & Couples
11. AB/AD with Medicare
12. AB/AD without Medicare
13. OAA with Medicare
14. OAA with Medicare Part B
Only
15. OAA without Medicare
16. CAF Children
17. Total Collections
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
Effective: January 1, 2011
Exhibit G – Attachment 2 – Report G.3 Page 124 of 221
Exhibit G – Attachment 2
Report G.3: Quarterly Balance Sheet
ABHA
Contract Year:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
□ Fiscal Year End
Report due within 50 calendar days after the end of each calendar quarter.
Full Accrual Modified Accrual Cash Basis
Category OHP Activities Under
this Agreement
CURRENT ASSETS
1. Cash and Cash Equivalents
2. Short-Term Investments
3. Investment Income Receivables
4. Health Care Receivables
5. Prepaid Expenses
6. Other Current Assets
7. Total Current Assets
OTHER ASSETS
1. Restricted Cash and Restricted Securities
2. Other Long-Term Investments
3. Other Assets (Please specify)
(a)
(b)
(c)
4. Total Other Assets
PROPERTY AND EQUIPMENT
1. Land, Buildings and Improvements
2. Furniture and Equipment
3. Leasehold Improvements
4. Other Property and Equipment
5. Total Property and Equipment
Effective: January 1, 2011
Exhibit G – Attachment 2 – Report G.3 Page 125 of 221
Category OHP Activities Under
this Agreement
6. TOTAL ASSETS
CURRENT LIABILITIES
1. Accounts Payable
2. Claims Payable
3. Incurred but Not Reported
4. Accrued Medical Incentive Pool
5. Loans and Notes Payable
6. Other Current Liabilities
7. (Reserved)
8. Total Current Liabilities
OTHER LIABILITIES
1. Loans and Notes Payable
2. Other Liabilities
3. Total Other Liabilities
4. TOTAL LIABILITIES
NET WORTH
1. Contributed Capital
2. Contingency Reserves
3. Retained Earnings/Fund Balance
4. Other Net Worth
5. Total Net Worth
6. TOTAL LIABILITIES AND NET WORTH
Revised, November 2009
Notes:
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
Effective: January 1, 2011
Exhibit G – Report G.3 Definitions Page 126 of 221
Report G.3 – Quarterly Balance Sheet
Definitions for this report:
Balance Sheet: A financial statement that has been developed using generally accepted accounting principles
and that shows the financial position of a business on a particular date.
If separate accounts are not kept for Covered Services, balance sheet information for such Covered Services
may be allocated using an estimation procedure. Such procedure and all assumptions must be disclosed in
Notes. This estimation procedure must be used throughout the report.
1. Cash and Cash Equivalents: Cash in the bank or on hand, available for current use. Cash equivalents
are investments maturing 90 calendar days or less from date of purchase.
2. Short-Term Investments: Principal amounts of investments in securities that are readily marketable,
maturing one year or less from date of purchase.
3. Investment Income Receivables: Income, including interest accrued or dividends earned on short term
or long term investments.
4. Health Care Receivables: Includes FFS, coordination of benefits, subrogation, copayments,
Reinsurance recoveries and non-affiliated provider receivables.
5. Prepaid Expenses: Any expenses paid and recorded in advance of its use or consumption in the
business, which properly represents a portion as an expense of the current period and a portion as an
asset on hand at the end of the period.
6. Other Current Assets: Other assets not included in the asset categories listed above, including any
other accounts receivable.
7. Total Current Assets: The sum of lines 1 through 6.
8. Restricted Cash and Restricted Securities: Assets restricted for statutory insolvency requirements
held for contract (per contract $250,000 minimum).
9. Other Long-Term Investments: Principal amounts of investments with a maturity longer than one
year from date of purchase or no stated maturity date.
10. Other Assets: Other assets, such as aggregate write-ins, bonds, preferred stocks, receivables from
securities, etc. (Please specify)
11. Total Other Assets: The sum of lines 8 through line 10.
12. Land, Buildings and Improvements: Net book value of land and buildings owned by ABHA, and any
improvements made to buildings, or improvements in progress.
13. Furniture and Equipment: Net book value of office equipment, including computer hardware and
software (where permitted), and furniture owned by ABHA.
14. Leasehold Improvements: Net book value of improvements to facilities not owned by ABHA.
Provide net amount (gross amount less amortization).
Effective: January 1, 2011
Exhibit G – Report G.3 Definitions Page 127 of 221
15. Other Property and Equipment: Net book value of other tangibles and, fixed assets that are not
included on Lines 12, 13, and 14.
16. Total Property and Equipment: The sum of lines 12 through line 15.
17. Total Assets: The sum of lines 7, 11 and 16.
18. Accounts Payable: Amounts due to creditors for the acquisition of goods and services (trade and
vendors rather than health care practitioners) on a credit basis.
19. Claims Payable: Claims reported and booked as payables claims (minus incentives and stop loss).
20. Incurred But Not Reported (IBNR): An estimate for claims which have been incurred as of the last
date of the report period for which Contractor is responsible but has not yet determined the specific
amount of liability.
21. Accrued Medical Incentive Pool: Liability for arrangements whereby ABHA agrees to share
Utilization savings with Individual Practice Associations, physician groups, or other providers.
22. Loans and Notes Payable: The principal amount on loans or notes due within one year.
23. Other Current Liabilities: Any payable amount other than direct health care services to affiliates and
any liabilities not included in the current liabilities categories listed above.
24. (reserved)
25. Total Current Liabilities: The sum of lines 18 through 24.
26. Loans and Notes Payable: Loans and notes signed by ABHA, not including current portion payable,
that are of a long term nature (liquidation not expected to occur within one year of the date of the
statement).
27. Other Liabilities: Other liabilities not included in the liabilities categories listed above.
28. Total Other Liabilities: The sum of lines 26 and 27.
29. Total Liabilities: The sum of lines 25 and 28.
30. Contributed Capital: Capital donated to ABHA.
31. Contingency Reserves: Reserves held beyond contingency purposes reported on Report G.3, line 8 as
defined in state statutes and regulations.
32. Retained Earnings/Fund Balance: The undistributed and unappropriated amount of surplus.
33. Other Net Worth: Other net worth items not reported on any other lines.
34. Total Net Worth: The sum of line 30 through 33.
35. Total Liabilities and Net Worth: The sum of lines 29 and 34.
Effective: January 1, 2011
Exhibit G – Attachment 3 – Report G.4 Page 128 of 221
Exhibit G – Attachment 3
Report G.4: ABHA’s Quarterly Statement of Revenue and Expenses
ABHA
Contract Year:
Subcontractor:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
□ Fiscal Year
Report due within 50 calendar days after the end of each quarter to be submitted for both
ABHA and risk based subcontractors.
Full Accrual Modified Accrual Cash Basis
Category OHP Activity under this
Agreement
REVENUES
1. Capitation
2. Other Health Care Revenues (please specify)
(a)
(b)
(c)
3. Total Revenues
HEALTH CARE EXPENSES
1. Health Care Expenses
(a) Staff Model
(b) Fee-for-Service
(c) Risk Models
(d) Other payment arrangements
2. Incentive Pool and Withhold Adjustments
3. Subcapitation Payments
4. Other health care expenses not included above.
(please specify)
5. LESS DEDUCTIONS FOR HEALTH CARE EXPENSES
(a) Third Party Resource (TPR) Recoveries
(b) Reinsurance Recoveries
Effective: January 1, 2011
Exhibit G – Attachment 3 – Report G.4 Page 129 of 221
Category OHP Activity under this
Agreement
(c) Subrogation Recoveries
6. TOTAL HEALTH CARE EXPENSES
ADMINISTRATIVE EXPENSES
1. ABHA
2. Subcontractor
3. MCO Provider Tax
4. Total Administrative Expenses
5. TOTAL EXPENSES
6. NET INCOME (LOSS)
7. Beginning Balance (ending balance from last quarterly report)
Retained Earnings/Fund Balances
8. Increase (Decrease) in Retained Earnings/Fund Balance
9. Other Changes
10. Balance at End of Current Reporting Period Retained Earnings/Fund
Balances
Accounting of Net Income (Loss) Recorded on Line 15:
ABHA shall submit a detailed description of how a net loss (quarterly or fiscal year end) and the impact to the
ABHA operations and what fiscal changes were necessary to cover the loss.
Additionally, describe how a fiscal year end net income will be utilized during the next fiscal year. This shall
include the amount to be retained, the amount to be reinvested, the timeline of reinvestment and a narrative
describing how the reinvestment will benefit the OHP Members and support mental health Stakeholders.
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
Effective: January 1, 2011
Exhibit G – Report G.3 - Definitions Page 130 of 221
Report G.4 – ABHA’s Quarterly Statement of Revenue and Expenses
Definitions for this report:
Statement of Revenue and Expenses: A financial statement reporting fully accrued revenues
and expenses under this Agreement for the period. ABHA shall indicate the accounting method
used for this report: Full accrual, modified accrual, or cash basis. Expenses should be
appropriately reported for health care and administrative expenses.
When ABHA reports an expense on Report G.4 Line 6 “Subcapitation payments”, ABHA shall
have subcontractors receiving subcapitation funds complete Reports G.4, G.4A, and G.4B.
ABHA shall attach subcontractor’s Reports G.4, G.4A, and G.4B with ABHA’s quarterly
statements when submitting them to DHS.
OHP Activity: The financial position of ABHA relating to activities that are associated with
Covered Services provided under the Oregon Health Plan (OHP) under this Agreement.
Allocation of expenditures between OHP and other line of business is permitted. If separate
accounts are not kept for the OHP, revenue and expenses for the OHP may be allocated using an
estimation procedure. Such a procedure and all assumptions must be disclosed in Notes to
Report G.4. This estimation procedure must be used throughout the reports. The assumptions
underlying the allocation must be based on a methodology that clearly represents the costs
associated with providing Covered Services to OHP Members.
Revenues
1. Capitation: The amount received by ABHA on a per member per month basis in advance
of and as payment for the provision of Covered Services to OHP Members enrolled with
COIHS over a defined period of time.
2. Other Health Care Revenues: Other revenues recognized as a result of other non-
capitated arrangements between ABHA and COIHS related to Covered Services provided
under this Agreement for OHP Members not included in the previous revenue categories
such as interest income on required OHP reserves, etc. Only OHP related revenue is to
be reported on this Report G.4.
3. Total Revenues: The sum of lines 1 and 2.
Health Care Expenses: These are the costs that can be identified specifically with activities
associated with providing health care services to OHP Members. Examples of health care costs
are compensation of clinical employees for the time devoted to activities associated with
providing covered health care Services to OHP Members, the cost of material acquired,
consumed, or expended specifically for the purpose of such activities, equipment and capital
expenditures specifically identified with such activities, and travel expenses incurred specifically
to carry out such health care service activities.
Effective: January 1, 2011
Exhibit G – Report G.3 - Definitions Page 131 of 221
4. Health Care Expenses:
a. Staff Model: Amounts paid by ABHA for the provision of Covered Services to
enrolled OHP Members. Include salaries, fringe benefits, other compensations to
staff engaged in the delivery of Covered Services and to personnel engaged in
activities in direct support of the provision of Covered Services and other
expenses as defined in health care expenses above. Exclude expenses for
personnel time devoted to administrative tasks.
b. Fee for Service: Amounts paid for the provision of Covered Services dependent
on the actual number and nature of services provided to each OHP Member.
c. Risk Models: Amounts paid where the Provider receives a fixed amount and
assumes financial liability for the provision of Covered Services for OHP
Members, such as DRGs or Case Rates.
d. Other Payment Arrangements: Amounts paid under other Service payment
arrangements not included in above categories.
5. Incentive Pool and Withhold Adjustments: Adjustments made to expenses that reflect
the incentive pool and withhold activities.
6. Subcapitation Payments: Amounts paid by ABHA to a Provider in advance of and as
payment for actual receipt of Covered Services, either on a per-member-per-month basis,
or on the basis of a formula for allocation whereby the Provider assumes risk for the
provision of all Medically Appropriate Covered Services to OHP Members who are
enrolled with that Provider during the month.
7. Other health care expenses not included above. (please specify)
8. Deductions From Health Care Expenses:
a. TPR: Income earned from Medicare, third party resources, and other insurance
collections through coordination of benefits activities.
b. Reinsurance Recoveries: Amounts received from the reinsurer and those amounts
that have been billed to the reinsurer and not yet received.
c. Subrogation and other Tort/Estate Recoveries: Amounts received from other
liability insurance recoveries, including tort and estate collections.
9. Subtotal Health Care Expenses: The sum of lines 4 through 7 minus line 8a, 8b and 8c.
Administrative Expenses: Administrative costs are those associated with the overall
management and operations of ABHA related to OHP line of business.
Effective: January 1, 2011
Exhibit G – Report G.3 - Definitions Page 132 of 221
10. ABHA: All expenses by ABHA for administrative services such as claims and encounter
processing, contract services, financial services, member services, provider relations,
utilization management, and quality management.
11. Subcontractor: All expenses by subcontractor for administrative services such as claims
and encounter processing, contract services, financial services, member services, provider
relations, utilization management, and quality management.
12. MCO Provider Tax: Payment made for managed care taxes.
13. Total Administrative Expenses: The sum of lines 10 and 12.
14. Total Expenses: The sum of lines 9 and 13.
15. Net Income (Loss): The result of line 3 minus 14.
ABHA shall submit a detailed description of a net loss (quarterly or fiscal year end) and
the impact to ABHA operations and what fiscal changes were necessary to cover the loss.
Additionally, describe how a fiscal year end net income will be utilized during the next
fiscal year. This shall include the amount to be retained, the amount to be reinvested, the
timeline of reinvestment and a narrative describing how the reinvestment will benefit the
OHP Members and support mental health Stakeholders.
16. Beginning Balance of Period (ending balance from last quarterly report): The total
contributed capital, surplus notes, retained earnings/fund balance, and other items at the
beginning of the report period.
17. Increase (Decrease) in Retained Earnings/Fund Balance: Changes in retained
earnings/fund balance from the last report period to the current report period.
18. Other Changes: Changes in other items from the last report period to the current report
period.
19. Balance at End of Quarterly Reporting Period: Contributed capital, retained
earnings/fund balance and other items at the end of the report period.
Effective: January 1, 2011
Exhibit G – Attachment 4 – Report G.4.A Page 133 of 221
Exhibit G – Attachment 4
Report G.4.A: Health Care Expenses by Service Type
ABHA
Subcontractor:
Calendar Year:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
□ Fiscal Year
Report due at the same time as Report G.4 for both ABHA and risk based subcontractors,
within 50 calendar days after the end of each quarter.
Category OHP Activity under this
Agreement
Outpatient
Sub Acute & Other 24 hour Services
Inpatient
Prevention, Education and Outreach 1
Treatment Support Services & Supplies
Consumer Operated Services
Other Non-Encountered Services
TOTAL HEALTH CARE EXPENSES 2
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
1 When an expense is reported on Report G.4A Line 4, complete and attach Report G.4B-Prevention/Education/Outreach
Activities 2 Total of line 8 “TOTAL HEALTH CARE EXPENSES” on Report G.4A must equal line 9 “Total Health Care
Expenses” on Report G.4.
Effective: January 1, 2011
Exhibit G – Report G.4.A - Definitions Page 134 of 221
Report G.4.A – Health Care Expenses by Service Type
Definitions for this report:
1. ABHA: Complete and attach Report G.4A with its completed Report G.4. Include all
completed Reports G.4, G.4A and G.4B submitted by its subcontractors with its own
Reports G.4, G.4A, and G.4B.
2. Subcontractor: Complete and attach Report G.4A with its completed Report G.4, then
submit the completed G.4, G.4A and G.4B reports to the Contractor.
3. Outpatient: Expenses for outpatient covered health care services. Exclude expenses for
personnel time devoted to administrative tasks.
4. Sub Acute & Other 24 hour Services: Expenses for services provided in lieu of
hospitalization or as a step down from Acute Care hospitalization.
5. Inpatient: All inpatient hospital expenses costs while confined to an Acute Inpatient
Hospital Psychiatric Care Setting.
6. Prevention, Education and Outreach: Outreach, Education and Prevention to OHP
Members, not otherwise reportable as a service Encounter, treatment support services and
supplies, or Consumer operated services. This category does not include marketing
activities, provider training, or development and distribution of member handbooks.
7. Treatment Support Services & Supplies: Items or direct services provided to
individuals as alternatives to Traditional Services and Flexible Services that are not
otherwise reported as CPT or HCPCS codes.
8. Consumer Operated Services: Supportive services provided by one or more Consumers
or a Consumer run agency to groups and Family members which cannot be captured as
CPT or HCPCS codes. (e.g., a drop in center, telephone warm line, support group, etc.)
9. Other Non-Encountered Services: Other health care expenses for services not reported
in above categories
10. Total Health Care Expenses: The sum of lines 1 through 7. Total of line 8 “TOTAL
HEALTH CARE EXPENSES” on Report G.4A must equal line 9 “Total Health Care
Expenses” on Report G.4.
Effective: January 1, 2011
Exhibit G – Attachment 5 – Report G.4.B Page 135 of 221
Exhibit G – Attachment 5
Report G.4.B: Prevention/Education/Outreach Activities
ABHA
Subcontractor:
Calendar Year:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
Report due at the same time as Report G.4 and G.4A - within 45 calendar days after the
end of each quarter, to be submitted for both ABHA and risk based subcontractors.
1. Provide information on Prevention/Education/Outreach activities for OHP enrolled members.
2. Report only those activities that cannot be otherwise reported using CPT codes.
No. Activity Number of
Activities
Time 3
Cost 4 No. of Members
(actual or estimate)
1 PEO 1- Public Information
2 PEO 2 – Community Education
3 PEO 3 – Parent/Family Education
4 PEO 4 – Alternative Activities
5 PEO 5 – Community Mobilization
6 PEO 6 – Life Skills Development
7 PEO 7 – Prevention Support Activities
8 PEO 8 – Community Based Outreach
9 PEO 9 – Services Integration
10 OTHER
11 TOTAL PEO EXPENSES
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
3 Actual time spend with members, reported in 15 minute increments. Time does not apply for PEO1.
4 Cost allocation for activity to include preparation, travel, equipment, and level of staff person.
Effective: January 1, 2011
Exhibit G – Report G.4.B – Definitions Page 136 of 221
Report G.4.B – Prevention/Education/Outreach Activities
Definitions for this report:
1. PEO 1 Public Information: Presentation of accurate targeted messages and promotional material on
mental health and substance abuse issues, such as suicide and teen pregnancies, to increase awareness of
behavioral health. May include information seminars, electronic and print media. (Time does not apply
for this activity)
2. PEO 2 Community Education: Community educational sessions with clear goals and objectives
designed for a specific group that promotes a change in attitude and behaviors that may lead to
behavioral health problems. May be ongoing and sequential.
3. PEO 3 Parent/Family Education: Educational sessions aimed at parents and Family members. May
be one time only or ongoing, sequential sessions or workshops with defined goals and objectives. May
include early childhood development, parenting skills, parent/child communication, and health families.
4. PEO 4 Alternative Activities: Alternative activities that provide challenging positive growth
experiences, leading to the development of self-reliance and independence. Programs offer healthy
alternatives for leisure/free time within the community Setting, e.g., hiking club, ropes course.
5. PEO 5 Community Mobilization: Community mobilization activities to deal effectively with
behavioral health issues within the community, such as developing partnerships with schools/businesses,
developing neighborhood coalitions, or training and technical assistance to coalitions.
6. PEO 6 Life Skills Development: Life skills development activities that assist individuals in developing
or improving critical life skills. Must be ongoing, sequential learning activities or sessions that focus on
the development of skills in decision making, coping with stress, values awareness, problem solving,
conflict resolution, resistance skills, and self esteem.
7. PEO 7 Prevention Support Activities: Activities that support individuals in daily living or coping
skills, such as warm lines and peer supports.
8. PEO 8 Community Based Outreach: Activities provided in community Settings that attempt to engage
individuals who might not otherwise access or seek out Traditional Services, such as Outreach to
homeless individuals.
9. PEO 9 Services Integration: Includes participation in multi-disciplinary teams and community
meetings where services are being discussed for an OHP Member who is not currently in services with a
mental health provider.
10. OTHER: Expenses for other Prevention, Education, Outreach activities not reported in above
categories.
11. TOTAL PEO EXPENSES: The sum of lines 1 through 10.
Effective: January 1, 2011
Exhibit G – Attachment 6 – Report G.5 Page 137 of 221
Exhibit G – Attachment 6
Report G.5: Fiscal Year Cash Flow Analysis for Corporate Activity-Indirect Method
ABHA
Report Period: through
Report is due within 80 calendar days after the end of ABHA’s fiscal year.
Provide the cash flow information for Corporate Activity. Note that cash flow resulting from an increase in
operating assets, a decrease in operating liabilities, and a payment out is a debit. Note that cash flows resulting
in receipt of cash or proceeds are credits.
Cash Flows Provided by ABHA
Corporate
Activity
OPERATING
ACTIVITIES
1. Net Income (loss)
Adjustment to reconcile
net income (loss to net
cash)
2. Depreciation and
Amortization
(Increase)/Decrease in
Operating Assets
3. Health Care
Receivables
4. Other Operating Assets
Increase (Decrease) in
Operating Liabilities
5. Unearned Capitation
Amounts
6. Accounts Payable
7. Accrued Incentive Pool
8. Other Operating
Activities
9. Claims Payable /IBNR
10. NET CASH PROVIDED (USED) FROM OPERATING ACTIVITIES
INVESTING
ACTIVITIES
11. Receipts from Sale of Investments
12. Receipts for Sales of Property and Equipment
13. Payments for Purchases of Investments
14. Payments for Purchase of Property and Equipment
Effective: January 1, 2011
Exhibit G – Attachment 6 – Report G.5 Page 138 of 221
Cash Flows Provided by ABHA
Corporate
Activity
15. Other Increase (Decrease) in Cash Flow for
Investing Activities
16. NET CASH PROVIDED (USED) BY INVESTING ACTIVITIES
FINANCING
ACTIVITIES
FINANCING
ACTIVITIES cont.
17. Proceeds from Paid in Capital or Issuance of Stock
18. Loan Proceeds
19. Principal Payments on Loans
20. Dividends Paid
21. Principal Payments under Lease Obligations
22. Other Cash Flow Provided by Financing Activities
23. NET CASH PROVIDED (USED) by FINANCING ACTIVITIES
24. NET INCREASE/(DECREASE) in CASH and CASH EQUIVALENTS from
OPERATING, INVESTING and FINANCING ACTIVITIES
25. CASH and CASH EQUIVALENTS at BEGINNING OF REPORT PERIOD
(BEGINNING OF FISCAL YEAR)
26. CASH and CASH EQUIVALENTS at END of REPORT PERIOD
27. CHANGE in CASH/CASH EQUIVALENTS for FISCAL YEAR
REPORTING
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
Effective: January 1, 2011
Exhibit G – Report G.5 - Definitions Page 139 of 221
Report G.5 – Fiscal Year Cash Flow Analysis for Corporate Activity Indirect Method
Definitions for this report:
ABHA shall provide a Cash Flow Analysis report for the corporate fiscal year for OHP business
within 80 days after the end of that fiscal year.
ABHA Corporate Activity: Total financial information of any relevant organization,
partnership, or joint venture incorporated under or subject to the provisions of ORS Chapters 60,
65, 190 and 732.005. The Corporate Activity for ABHA is defined as a ‘vendor’ with the State
Controller’s Oregon Accounting Manual, policy 30.40.00.102 and DHS procedure “Contractual
Governance”.
Cash Flow Provided by Operating Activities: Financial report estimating cash generated or
lost from operating activities.
1. Net Income (Loss): Report OHP Corporate Activity from Report G.4, Line 15 (fiscal
year end).
2. Depreciation and Amortization: Depreciation on property, plant and equipment, and
amortization on land.
3. Health Care Receivable: Report any cash flow generated or lost by changes in health
care receivables. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
4. Other Operating Assets: Report any cash flow generated or lost by changes in other
operating assets. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
5. Unearned Capitation Amounts: Report any cash flow generated or lost by changes in
unearned capitation. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
6. Accounts Payable: Report any cash flow generated or lost by changes in accounts
payable. Include non-cash or non-cash equivalent transactions. Remove the effects of all
deferrals of receipts and payments and accruals of receipts and payments.
7. Accrued Incentive Pool: Report any cash flow generated or lost by changes in accrued
incentive pool. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
8. Other Operating Liabilities: Report any other cash flow generated or lost by changes
in other operating liabilities. Include non-cash or non-cash equivalent transactions.
Remove the effects of all deferrals of receipts and payments and accruals of receipts and
payments.
Effective: January 1, 2011
Exhibit G – Report G.5 - Definitions Page 140 of 221
9. Claims Payable/IBNR: Report any cash flow generated or lost by changes in claims
payable. Included non –cash or non-cash equivalent transactions. Remove the effects of
all deferrals or receipts and payments and accruals of receipts and payments.
10. Net Cash Provided (Used) from Operating Activities: Sum of lines 1 through 9. To
arrive at net cash provided by operating activities, remove from net income the effects of
all deferrals of receipts and payments.
Cash Flows Provided by Investing Activities: Financial report showing the cash generated or
lost from different investing activities.
11. Receipts from Sale of Investments: Cash generated by the transfer of cash out of either
short-term or long-term investment transactions, including restricted cash reserves and
other assets that relate to transactions reported in Report G.3.
12. Receipts for Sales of Property and Equipment: Cash generated by the transfer of cash
into property and equipment sales transactions reported in Report G.3. Include any
advance payments, down payments or other payments made at the time of purchase or
shortly before or after the purchase of the property and equipment and productive assets
including leasehold improvements.
13. Payments for Purchases of Investments: Cash lost by the transfer of cash into either
short-term or long-term investment transactions reported in Report G.3. Include cash lost
by transfer of cash into restricted cash reserves and other assets that relate to transactions
reported in Report G.3.
14. Payments for Purchases of Property and Equipment: Cash lost by the transfer of cash
into property and equipment sales transactions reported in Report G.3. Include advance
payments, down payments or other amounts paid at the time of purchase or shortly before
or after the purchase of the property and equipment.
15. Other Increase (Decrease) in Cash Flow for Investing Activities: Report any other
cash flow generated or lost by changes in investing activities.
16. Net Cash Provided (Used) by Investing Activities: Sum of lines 11 through 15.
17. Cash Flows Provided by Financing Activities: Financial report showing the cash
generated or lost from different financing activities.
18. Proceeds from Paid in Capital or Issuance of Stock: Cash generated from paid in
capital surplus or issuance of stock.
19. Loan Proceeds: Cash generated by the transfer of cash from loan proceeds transactions.
20. Principal Payments of Loans: Cash payments for loan obligations.
Effective: January 1, 2011
Exhibit G – Report G.5 - Definitions Page 141 of 221
21. Dividends Paid: Cash payment for dividends reported in Report G.3.
22. Principal Payments under Lease Obligations: Cash payments for lease obligations.
23. Other Cash Flow Provided by Financing Activities: Any cash flow generated or lost
by the transfer of cash in a financial transaction.
24. Net Cash Provided (Used) by Financing Activities: Sum of lines 17 through 22.
25. Net Increase/(Decrease) in Cash and Cash Equivalents: From operation, investing
and financial activities. The sum of lines 10, 16 and 23.
26. Cash and Cash Equivalents at Beginning of Report Period: The total net cash
provided by operating activities, by investing activities, and by financing activities at the
beginning of the fiscal year specified in the last fiscal year Report G.5, line 24.
27. Cash and Cash Equivalents at End of Reporting Period: Line 24 of the latest fiscal
year Report G.5.
28. Change in Cash/Cash Equivalents for Fiscal Year: Line 25 minus Line 26.
Effective: January 1, 2011
Exhibit G – Attachment 7 – Report G.6 Page 142 of 221
Exhibit G – Attachment 7
Report G.6 – Disclosure of Compensation
ABHA
This report shall be completed at the end of the contract year and is due within 80 days following the end
of the contract year. The compensation and benefit amounts are the total for the contract year. As
specified in ORS 414.72 5, prepaid health care plans must report the three (3) highest executive salary and
benefit expenses paid to any executive as defined below:
"Executive" means a person having administrative or supervisory authority in ABHA’s organization, without
regard to title, including but not limited to the chief executive, financial, administration, or information officer;
chairperson; directors including the medical director; vice presidents; and managers.
OHP Line of Business
(1)(2)(3)(4)(5)
Name and Principal Position Gross Salary*1 Payroll-Related All Other *3
Benefits*2 Compensation TOTALS____________________________________________
Name and Position of Highest
Compensated Executive
Name:
Position:
Name and Position of Highest
Compensated Executive
Name:
Position:
Name and Position of Highest
Compensated Executive
Name:
Position:
*1 Disclose the amounts of OHP compensation (W2 Reportable) paid by ABHA for Executives. If an
Executive performs OHP work and non-OHP work compensation must be reasonably allocated between OHP
and non-OHP businesses. Method of allocation must be disclosed. Please attach narrative of allocation method
utilized. Only OHP related compensation is disclosed on this form.
*2 Including, but not limited to, health, life and disability insurance premiums and retirement plan contributions
paid by ABHA for the Executive’s benefit.
*3 Anything of value that the Executive received because of the relationship, not already reported in Column
(2) or Column (3) including items reported on the employee W2 that are not wages or benefits.
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
Effective: January 1, 2011
Exhibit G – Attachment 7 – Report G.6 Page 143 of 221
Exhibit G – Attachment 8
Report G.7 – Financial Reporting Related to Paid Claims
Instructions:
1. Include all compensation subcontracts with providers that were in effect anytime during the Contract
year, except fee for service subcontracts.
2. Use a separate row for each subcontract.
3. Complete all columns that apply:
Column 1: "Description of Subcontract" describe the nature of the subcontract (subcapitation,
performance bonus, risk sharing, risk withhold, etc.)
Column 2: "Subcontract Effective Date" is the first day within the contract year that the
subcontract was effective. This will normally be the first day of the contract year, but if
the subcontract covers only a portion of the contract year, it may be different.
Column 3: "Subcontract Expiration Date" is the last day within the contract year that the
subcontract was effective. This will normally be the last day of the contract year, but if
the subcontract covers only a portion of the contract year, it may be different.
Column 4: "Rendering Provider ID" is the identifier used in the MMIS.
Column 5: "Rendering Provider Name" is the name of the Participating Provider.
Column 6: "Population Covered by Subcontract" if all of the OHP Members are covered under
the subcontract, enter "All"; if the population covered is restricted in any way (such as by
age, gender, or geographic area), describe the restriction.
Column 7: "Services/Claim Types Covered by Subcontract" if all services normally covered
under the Contract are covered by the subcontract, enter "All"; if the services covered
under the subcontract are restricted in any way, describe the restriction.
Column 8: "Prepayment Amount" amount paid under the subcontract on a prepaid basis.
Column 9: "Withhold %" the percentage of payment withheld under the subcontract for the
purpose of sharing risk. (Enter the percentage as a decimal, (for example, for 20%
enter .20).
Column 10: "Withhold Amount Reimbursed" amount withheld under Column 9 that was
reimbursed to the subcontractor.
Column 11: "Settlement Amount" amount of settlement payments to the provider, including but not
limited to bonuses, quality and utilization incentives, infrastructure investment and
program directed expenses. (Do not include reimbursements accounted for in Column
10.)
Column 12: "Other Compensation Amount" any other amount that has not already been listed or
paid on a fee schedule.
Effective: January 1, 2011
Exhibit G – Attachment 7 – Report G.6 Page 144 of 221
Report G.7 – Financial Reporting Related to Paid Claims (continued)
ABHA
Report Period: through
Report is due September 20th of each Contract year, for the previous contract year.
Description of Subcontract
Subcontract
Effective Date
Subcontract
Expiration
Date
Rendering
Provider ID
Rendering Provider
Name
Population Covered by
Subcontract (specify
restrictions if applicable)
Services/Claim Types
Covered by Subcontract
(specify restrictions if
applicable)
Prepayment
Amount
Withhold
%
Withhold
Amount
Reimbursed
Settlement
Amount
Other
Compensation
Amount
Effective: January 1, 2011
Exhibit I Page 145 of 221
Exhibit I – Third Party Resources and Personal Injury Liens
Capitation rates specified in this Agreement are based in part on projected third party recoveries. ABHA's
failure to submit third party recovery data or pursue recoverable third party recovery obligations during the term
of this Agreement may create a claim for reimbursement to the extent that would be limited to the requirements
of federal law.
1. ABHA shall take all reasonable actions to pursue recovery of Third Party Resources for Covered
Services provided during the period covered by this Agreement. “Third Party” means any individual,
entity, or program that is, or may be, liable to pay all or part of the cost of any Covered Service
furnished to an OHP Member and as defined in Exhibit A of this Agreement.
2. ABHA will develop and implement written policies describing its procedures for Third Party Resource
recovery consistent with Third Party Resource recovery requirements in 42 USC 1396a(a)(25) and 42
CFR 433 Subpart D. At a minimum, the policies and procedures shall include the following information.
a. Identifying Third Party Resource.
(1) ABHA shall notify COIHS, within 15 days from the time that ABHA learns that an OHP
Member might have other health insurance.
(2) ABHA shall immediately report that OHP Member has a potential third party claim for
personal injuries, or has made a claim or begun an action to enforce such claim, as those
terms are defined in ORS 416.510, to COIHS.
(3) To the extent authorized by law, COIHS will share client and claim information they
receive with ABHA to assist in identifying Third Party Resources.
b. Determining the Liability of Third Party Resource.
(1) ABHA shall request OHP Members to cooperate in securing payment from Third Party
Resources, except when the client asserts good cause as defined in OAR 461-120-0350.
(2) If ABHA is unable to gain cooperation from the OHP Member or OHP Member
Representative or a Third Party Resource in pursuing the Third Party Resource, or if the
OHP Member asserts good cause; ABHA shall notify COIHS, of their refusal to
cooperate, and provide such records and documentation as may be requested from the
Medical Payment Recovery Unit.
c. Cost-avoidance.
(1) Cost-avoidance is defined as a method for avoiding payment of Medicaid claims when
Medicare or other insurance resources are available to the OHP Member. Using this
method, whenever ABHA is billed first, claims are denied and returned to the
provider who is instructed to bill and collect from liable Third Party Resources. Cost-
avoidance also includes payment avoided when the provider bills the Third Party
Resource first.
(2) ABHA may not refuse payment for Covered Services based solely on a Diagnosis code if
there is no documentation of a potential Third Party Resource other than the Diagnosis.
Effective: January 1, 2011
Exhibit I Page 146 of 221
(3) ABHA may not delay payment after a provider notifies ABHA that the provider cannot
obtain recovery from a Third Party Resource after making reasonable efforts, or cannot
obtain information or cooperation needed from OHP Member or a Third Party Resource
to obtain recovery from a Third Party Resource. Upon such notification, ABHA shall
process the claim as a Valid Claim however, ABHA may pursue alternative remedies
under Subsection b of this Section 2, or may seek to recover payment as provided in
Subsection d of this Section 2.
d. Pay and Chase
Pay and Chase is defined as a method used where ABHA pays the claim and then attempts to
recover from liable Third Party Resources.
e. Procedures for identifying and requesting payment from a Third Party Resource that applies to a
personal injury.
(1) ABHA’s recourse for obtaining timely assignment of the rights to recovery or the
assignment of lien rights shall be the process provided in ORS 416.510 to 416.610 and
OAR 461-195-0301 to 461-195-0350. ABHA shall not request an assignment of right to
recovery or assignment of a lien right from an OHP Member or OHP Member
Representative.
(2) When another party may be liable for a personal injury, ABHA may make the payments
and (consistent with Paragraph a, of this Subsection e) place a lien against a judgment,
settlement or compromise. Once ABHA has made the payment for Covered Services and
a lien has been sought, no additional billing or claim for enhanced reimbursement (e.g.,
balance billing) to the third party or to the OHP Member or their financially responsible
representative is permitted.
f. ABHA shall maintain records of ABHA’s actions and subcontractors’ actions related to Third
Party Resource recovery, and make those records available for review and review consistent with
the provisions of this Agreement.
(1) ABHA shall report all Third Party Resource payments to COIHS using Report G.2,
Current OHP Members with Third Party Resources (Quarterly Report), on a quarterly
basis within 50 calendar days after the end of each calendar quarter.
(2) ABHA shall maintain records of Third Party Resource recovery actions that do not result
in recovery, including ABHA’s written policy establishing the threshold for determining
that it is not cost effective to pursue recovery action.
(3) ABHA shall provide documentation about personal injury recovery actions and
documentation about personal injury liens to COIHS.
3. ABHA may not refuse to Provide Covered Services, and shall require that its subcontractors may not
refuse to Provide Covered Services, to an OHP Member because of a Third Party Resource’s potential
liability for payment for the Covered Service.
4. ABHA is the payer of last resort when there is other insurance or Medicare in effect. At COIHS
discretion or at the request of the ABHA, COIHS may retroactively disenroll an OHP Member to the
Effective: January 1, 2011
Exhibit I Page 147 of 221
time the OHP Member acquired Third Party Resource insurance if so allowed by DHS. If the Member’s
Enrollment is inconsistent with OHP managed care Enrollment rules 410-141-0060 through 410-141-
0080, an OHP Member is retroactively disenrolled and DHS will Recoup all Capitation Payments to
ABHA after the effective date of the Disenrollment. ABHA and its subcontractors may not seek to
collect from the OHP Member (or any financially responsible representative of the OHP Member) or
any Third Party Resource, any amounts paid for any Covered Services provided on or after the date of
Disenrollment.
5. ABHA shall comply with 42 USC 1395y(b), which gives Medicare the right to recover its benefits from
employers and workers’ compensation carriers, liability insurers, automobile or no fault insurers, and
employer group health plans before any other entity including ABHA or its subcontractor.
a. Where Medicare and ABHA have paid for services, and the amount available from the Third
Party Resource is not sufficient to satisfy the claims of both programs to reimbursement, the
Third Party Resource must reimburse Medicare the full amount of its claim before any other
entity, including ABHA or its subcontractor, may be paid.
b. If the Third Party Resource has reimbursed ABHA or its subcontractor, or if an OHP Member,
after receiving payment from the Third Party Resource, has reimbursed ABHA or its
subcontractor, ABHA or its subcontractor must reimburse Medicare up to the full amount
ABHA/subcontractor received, if Medicare is unable to recover its payment from the remainder
of the Third Party Resource payment.
c. Any such Medicare reimbursements described in this section are ABHA’s responsibility on
presentation of appropriate request and supporting documentation from the Medicare carrier.
ABHA shall document such Medicare reimbursements in its report to DHS, described in Section
2, Subsection f, Paragraph (1), of this Exhibit.
6. When engaging in Third Party Resource recovery actions, ABHA and subcontractors shall comply with
federal and state confidentiality requirements pursuant to Exhibit E, Section 7, (HIPAA), including
without limitation, the federal (42 CFR Part 2) and state (ORS 426.460 and ORS 179.505)
confidentiality laws and regulations governing the identity and client records of OHP Members. DHS
considers the disclosure of OHP Member claims information in connection with ABHA’s Third Party
Resource recovery actions a purpose that is directly connected with the administration of the OHP
program.
Effective: January 1, 2011
Exhibit J Page 148 of 221
Exhibit J – Prevention and Detection of Fraud, Waste and Abuse
ABHA shall have in place administrative and management arrangements, internal controls, policies or
procedures and a mandatory compliance plan that are designed to prevent, detect and guard against fraud, waste
and abuse as they relate to the OHP. This may include operational policies and controls in areas such as
Grievance resolution, provider credentialing and contracting, provider and staff education, and Corrective
Action Plans to prevent potential fraud, waste and abuse activities. ABHA shall review its fraud, waste and
abuse policies annually. If ABHA is also a Medicare contractor, the fraud, waste and abuse policies established
by ABHA to meet CMS standards shall be deemed sufficient to meet DHS’ requirements for fraud, waste and
abuse prevention and monitoring. Fraud, waste and abuse policies and procedures shall be reviewed annually.
1. ABHA’s fraud, waste and abuse activities shall include, at minimum, the following:
a. Written policies, procedures, and standards of conduct that articulate ABHA’s commitment to
comply with all applicable Federal and state standards to guard against fraud, waste and abuse;
b. Provide detailed information about the False Claims Act established under sections 3729 through
3733 of title 31, United States Code, administrative remedies for false claims and statements
established under chapter 38 of title 31, United States Code, any Oregon laws pertaining to civil
or criminal penalties for false claims and statements, and whistleblower protections under such
laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in
Federal health care programs (as defined in 42 USC 1320a-7b);
Such Oregon laws shall include the following: ORS 411.670 to 411.690 (submitting wrongful
claim or payment prohibited; liability of person wrongfully receiving payment; amount of
recovery); ORS 646.605 to 646.656 (unlawful trade practices); ORS chapter 162 (crimes related
to perjury, false swearing and unsworn falsification); ORS chapter 164 (crimes related to theft);
ORS chapter 165 (crimes involving fraud or deception), including but not limited to ORS
165.080 (falsification of business records) and ORS 165.690 to 165.698 (false claims for health
care payments); ORS 166.715 to 166.735 (racketeering – civil or criminal); ORS 659A.200 to
659A.224 (whistleblowing); ORS 659A.230 to 659A.233(whistleblowing); OAR 410-120-1395
to 410-120-1510 (program integrity, sanctions, fraud, waste and abuse); and common law claims
founded in fraud, including Fraud, Money Paid by Mistake and Money Paid by False Pretenses).
ABHA understands that this description of the laws that must be included in the employee
handbook under this section of this Agreement does not limit the authority of DMAP or any
health oversight agency or law enforcement entity from fully exercising its legal authority or
from pursuing legal recourse to the full extent of the law.
c. Provide as part of the written policies, detailed provisions regarding ABHA’s policies and
procedures for detecting and preventing fraud, waste and abuse.
d. Include in any employee handbook for the ABHA, a specific discussion of the laws described in
Subsection b., of this section, the rights of employees to be protected as whistleblowers, and
ABHA’s policies and procedures for detecting and preventing fraud, waste and abuse.
e. The designation of a compliance officer and a compliance committee that are accountable to
senior management, to monitor fraud, waste and abuse activities;
f. Effective training and education for the compliance officer and ABHA’s employees;
Effective: January 1, 2011
Exhibit J Page 149 of 221
g. Effective lines of communication between the compliance officer and ABHA’s employees;
h. Enforcement of standards that guard against fraud, waste and abuse through well publicized
disciplinary guidelines;
i. Provision for internal monitoring and auditing; and
j. Provision for prompt response to detected offenses and for development of corrective action
initiatives relating to this Agreement.
2. Services under this Agreement may not be provided by the following persons (or their affiliates as
defined in the Federal Requisition Regulations): (a) Persons who are currently suspended, debarred or
otherwise excluded from participating in procurement activities under the Federal Acquisition
Regulation or from participating in non-procurement activities under regulations issues pursuant to
Executive Order No. 12549 or under guidelines implementing such order, (b) Persons who are currently
excluded from the Medicaid participation under Section 1128 or Section 1128A of the Act.
3. ABHA shall not refer OHP Members to such persons and shall not accept billings for services to OHP
Members by such persons.
4. ABHA may not knowingly: (1) have a person described in (a) above as a director, officer, partner, or
person with beneficial ownership of more than 5% of ABHA’s equity, or (2) have an employment,
consulting, or other agreement with a person described in 1(a) above for the provision of items and
services that are significant and material to ABHA’s obligations under this Agreement.
5. ABHA is required to promptly refer all verified cases of fraud, waste and abuse, including fraud by
employees and subcontractors of the organization to the Medicaid Fraud Control Unit (MFCU),
consistent with the Memorandum of Understanding between DHS and the MFCU. ABHA may also
refer cases of suspected fraud, waste and abuse to the MFCU prior to verification.
6. Examples of cases that should be referred:
a. Providers who consistently demonstrate a pattern of intentionally reporting encounters or
services that did not occur. A pattern would be evident in any case where 20% or more of
sampled or audited services are not supported by documentation in the Clinical Records;
b. Providers who consistently demonstrate a pattern of intentionally reporting overstated or up-
coded levels of service. A pattern would be evident by 20% or more of sampled or audited
services that are billed at a higher level procedure code than is documented in the Clinical
Records;
c. Any verified case where the provider purposefully altered, falsified, or destroyed Clinical Record
documentation for the purpose of artificially inflating or obscuring compliance rating or
collecting Medicaid payments not otherwise due;
d. Providers who intentionally or recklessly make false statements about the credentials of persons
rendering care to OHP Members;
e. Providers who intentionally fail to render Medically Appropriate Covered Services to OHP
Members;
Effective: January 1, 2011
Exhibit J Page 150 of 221
f. Providers who knowingly charge OHP Members for services that are covered or intentionally
balance bill an OHP Member the difference between the service charge and ABHA’s payment,
in violation of DHS rules;
g. Any case of theft, embezzlement or misappropriation of Title XIX or Title XXI program money.
7. An incident with any of the referral characteristics listed above should be referred to the MFCU. ABHA
may also refer cases of suspected fraud, waste and abuse to the MFCU, with a copy to COIHS.
8. The MFCU phone number is (971) 673-1880, address 1515 SW 5th Avenue, Suite 410, Portland,
Oregon 97201, and fax (971) 673-1890.
9. Incidents of verified or suspected fraud, waste or abuse by an OHP Member should be reported to DHS
Fraud Investigation Unit, P.O. Box 14150, Salem, Oregon 97309-5027, phone number (503) 378-6826,
facsimile number (503) 378-1525, with a copy to COIHS.
10. ABHA shall promptly report all fraud, waste and abuse as required under this section to the MFCU.
ABHA shall also notify COIHS of referrals to MFCU of complaints of fraud, waste and abuse that
warrant investigation. This notification shall include the following information:
a. Provider’s name, Oregon Medicaid Provider Number, and address;
b. Type of Provider
c. Source of complaint;
d. Nature of complaint;
e. The approximate range of dollars involved;
f. The disposition of the complaint when known; and
g. Number of complaints for the time period.
11. ABHA shall cooperate with the MFCU and the DHS Fraud Unit and allow them to inspect, evaluate, or
audit books, records, documents, files, accounts, and facilities as required to investigate an incident of
fraud, waste or abuse.
12. In the event that ABHA reports suspected fraud, or learns of an MFCU or DHS Fraud Unit
investigation, ABHA shall not notify or otherwise advise its subcontractors of the investigation so as not
to compromise the investigation.
Effective: January 1, 2011
Exhibit K Page 151 of 221
Exhibit K –Provider Capacity Assurance Report
ABHA shall submit to DHS this report as follows:
• This portion of Exhibit K, which excludes Exhibit K, Attachment 2, Report K.1 is due
upon effective date of this Agreement and immediately upon significant changes; and
• At any time there has been a significant change (as defined by DHS) in ABHA’s
operations that would affect adequate capacity and services, including:
∗ Changes in ABHA’s services, benefits, geographic service area or payments, or;
∗ Enrollment of a new population with ABHA; or
∗ Exhibit K – Attachment 2, Report K.1 is due by February 15 of each contract
year, with a reporting period of January 1 through December 31 of the previous
contract year.
42 CFR 438.206 “Availability of Services” and 42 CFR 438.207 “Assurances of Adequate
Capacity and Services” require ABHA to ensure to COIHS, with supporting documentation, that
all Services covered under this Agreement are available and accessible to OHP Members and
that ABHA demonstrates adequate Provider capacity.
Provide the following information of how ABHA requires and monitors adequate mental health
Provider capacity. If any of the activities are subcontracted, describe how ABHA provides
oversight and monitoring of the activities as well.
1.
a. How does ABHA or delegate(s) maintain a network of appropriate Providers to
sufficiently Provide adequate access to all Services covered under this Agreement
including Special Health Care Needs?
b. How does ABHA or delegate(s) monitor the network of appropriate Providers to
sufficiently Provide adequate access to all Services covered under this Agreement
including Special Health Care Needs?
2. If the network is unable to Provide necessary Services, covered under this Agreement, to
a particular OHP Member, how does BHA or delegate(s) Provide adequate and timely
Services out of network for an OHP Member, for as long as the ABHA or delegate(s) is
unable to Provide them within the network?
3.
a. How does ABHA or delegate(s) require Providers to meet DHS standards for
timely access to routine, urgent and emergent care and Services, taking into
account the urgency of the need for Services?
Effective: January 1, 2011
Exhibit K Page 152 of 221
b. How does ABHA or delegate(s) monitor compliance by Providers of timely
access to care and Services?
c. How does ABHA or delegate(s) monitor availability of Services when medically
necessary routine, urgent and emergent Services?
4. What corrective actions has ABHA or delegate(s) taken if there was a failure to comply
with any provision or timeliness of Services during the prior contract year? If, any, what
is the current status of the corrective action and compliance?
5. In the current contract year, what is ABHA or delegate(s) doing to Provide delivery of
Services in a culturally competent manner to all OHP Members, including those with
limited English proficiency and diverse cultural and ethnic backgrounds?
6. What does ABHA do to monitor subcontracted activities related to Provider capacity?
Be specific to each activity subcontracted.
7. Provide date of data set completion
8. ABHA shall submit a list of participating Qualified Mental Health Professional
practitioners and participating facilities to include the following elements:
Practitioner List
Name
Agency/Location
Telephone Number
Non-English Language Spoken
Facility List
Name of Facility
Psychiatric Day Treatment Facility
Psychiatric Residential Treatment Services Facility
Effective: January 1, 2011
Exhibit K Page 153 of 221
Exhibit K – Attachment 1 - Hospital Adequacy Report Instructions
As cited in ORS 441.094(5) and Exhibit B, Part II, Section 1.b.(6), ABHA shall have contracts
with local and regional hospitals for the provision of emergency and non-emergency
hospitalization for OHP Members.
This Hospital Adequacy Report is an annual report of hospital mental health admissions at
hospitals that are Participating Providers and hospitals that are not Participating Providers. DHS
shall review ABHA hospital utilization by ABHA annually to determine if all hospitals are being
adequately represented in the contracting process.
1. ABHA shall complete Exhibit K, Attachment 2, Report K.1 by February 15 of each
Contract year for reporting period of January 1 through December 31 of the previous
contract year.
2. The following benchmarks shall be monitored and evaluated to assess the adequacy of a
hospital network:
a. A minimum of 90% of ABHA’s total inpatient admissions shall be provided in
hospitals under contract with ABHA.
b. In those instances where the percentage of utilization falls below the 90%
inpatient admission benchmark or DHS finds that ABHA’s annual report of
hospital network is not adequate, DHS may determine if ABHA and hospital(s)
have both made a good faith effort to contract with each other.
3. The following are factors that DHS will consider when determining whether ABHA
made a good-faith effort to subcontract with a hospital:
a. The amount of time ABHA has been actively trying to negotiate a contractual
arrangement with the hospital(s) for the service involved;
b. The payment rates and methodology ABHA has offered to the hospital(s);
c. The payment rates and methodology the hospital has offered to ABHA.
d. Other hospital cost associated with non-financial contractual terms ABHA has
proposed, including prior-authorization and other utilization management policies
and practices;
e. ABHA’s track record with respect to claims payment timeliness, overturned
claims, denials, and hospital complaints; and
f. The hospital(s) stated reasons for not contracting with ABHA.
Effective: January 1, 2011
Exhibit K Page 154 of 221
Exhibit K – Attachment 2 - Report K.1
ABHA
Report Period __________________________though ________________________________
1. Complete the following table for the above period:
Provided at a
Contracted Hospital
Provided at a Non-
Contracted Hospital
Total
Inpatient Hospitals
Services – Provide
the number of
admissions for the
reporting period.
Comments:
________________________________________________________________________
________________________________________________________________________
____________
2. In the table below:
a. list the names of those hospitals with whom you have a contract, a Memorandum
of Understand or a Letter of Agreement ; and
b. list the names of those hospitals you use on a non-participating basis.
Hospitals with Contracts, MOUs, and
Letters of Agreement
Non- Participating Hospitals
Effective: January 1, 2011
Exhibit L Page 155 of 221
Exhibit L – Changes in Ownership
Changes in ownership is consolidation or merger of ABHA, or of a corporation or other entity or
person controlling or controlled by ABHA, with or into a corporation or entity or person, or any
other reorganization or transaction or series of related transactions involving the transfer of more
than 50% of the equity interest in ABHA or more than 50% of the equity interest in a corporation
or other entity or person controlling or controlled by ABHA, or
The sale, conveyance or disposition of all or substantially all of the assets of ABHA, or of a
corporation or other entity or person controlling or controlled by ABHA, in a transaction or
series of related transactions.
1. ABHA shall notify COIHS at least 105 calendar days prior to any changes in ownership
in this Agreement and shall reimburse COIHS for all legal fees reasonably incurred by
COIHS in reviewing the proposed assignment or transfer and in negotiating and drafting
appropriate documents.
2. ABHA shall provide COIHS with full and complete information of each person or
Corporation with an ownership or control interest (which equals or exceeds 5 percent) in
the managed care plan, or any Subcontractor in which ABHA has an ownership interest
that equals or exceeds 5 percent, consistent with 42 CFR 455.100 through 42 CFR
455.104.
3. ABHA shall notify COIHS of any changes of address, licensure status as a mental health
plan with DCBS or as a Medicare Advantage plan, or Federal Tax Identification Number
(TIN), within 5 days of the changes.
4. Failure to notify COIHS of any of the above changes may result in the imposition of a
remedial action from DHS and may require Corrective Action to correct payment
records, as well as any other action required to correctly identify payments to the
appropriate TIN.
5. ABHA understands and agrees that COIHS through this Agreement, ABHA is the
“Entity” that COIHS is engaging the expertise, experience, judgment, representations and
warranties, and certifications of ABHA designated in this Agreement. ABHA shall not
transfer, subcontract, reassign or sell its contractual or ownership interests, such that
ABHA is no longer available to provide COIHS with its expertise, experience, judgment
and representations and certifications, without first obtaining COIHS’ prior written
approval 90 days before such transfer, subcontract, reassignment or sale occurs.
6. As a condition precedent to obtaining COIHS’ approval, not later than 105 days before
the transfer, subcontract, reassignment or sale occurs, ABHA shall provide to COIHS all
of the following:
Effective: January 1, 2011
Exhibit L Page 156 of 221
a. The name(s) and address(es) of all directors, officers, partners, owners, or persons
or entities with beneficial ownership interest of more than 5% of the proposed
new Entity’s equity; and
b. Representation and warranty signed and dated by the proposed new Entity and by
ABHA that warrants and represents that the policies, procedures and processes
issued by the current ABHA will be those policies, procedures, or processes
provided to COIHS by ABHA or by ABHA within the past two years, and that
those policies, procedures and processes still accurately describe those used at the
time of the ownership change and will continue to be used once COIHS has
approved the ownership change request, except as modified by ongoing Contract
and Administrative Rule requirements. If ABHA and the proposed new Entity
cannot provide representations and warranties required under this subsection,
COIHS shall be provided with the new policies, procedures and processes
proposed by the proposed new Entity for review consistent with the requirements
of this Agreement; and
c. The financial responsibility and solvency information for the proposed new Entity
for COIHS review consistent with the requirements of this Agreement; and
d. ABHA’s assignment and assumption agreement or such other form of agreement,
assigning, transferring, subcontracting or selling its rights and responsibilities
under this Agreement to the proposed new Entity, including responsibility for all
records and reporting, provision of services to DMAP Members, payment of
Valid Claims incurred for dates of services in which ABHA has received a
Capitation Payment, and such other tasks associated with termination of ABHA’s
contractual obligations under this Agreement.
7. COIHS reserves the right to require ABHA to provide such additional information and/or
take such actions as may reasonably be required to assure full compliance with Contract
terms as a condition precedent to COIHS’ agreement to accept the assignment and
assumption or other agreement.
8. COIHS will review the information to determine that the proposed new entity is qualified
to perform all of the obligations under this Agreement and that the new entity meets the
financial solvency requirements and insurance requirements to assume this Agreement.
Effective: January 1, 2011
Exhibit M Page 157 of 221
Exhibit M – Practitioner Incentive Plans
1. ABHA shall comply with all requirements of this Exhibit to ensure compliance with Sections
4204(a) and 4731 of the Omnibus Budget Reconciliation Act of 1990 that concern practitioner
incentive plans. The purpose of this Act is to ensure that OHP Members are not being denied
access to Medically Appropriate referral services based on financial incentives. ABHA shall not
set into place any financial incentives which reduce or limit provision of Covered Services to OHP
Members as specified in this Agreement.
2. ABHA shall complete and submit to DHS Report M.1: Practitioner Incentive Plan Disclosure,
under the following circumstances:
a. On the effective date of this Agreement;
b. At least 55 calendar days before the effective date of changes to the referral incentive
arrangements which results in a change in the amount of risk or Stop Loss Coverage or a
change in the risk formula to include coverage of services not provided by the practitioner
or practitioner group which were not previously included in the formula;
c. Within 20 calendar days of COIHS request; and
d. On the effective date of any amendment to this Agreement that extends ABHA’s Service
Area.
3. ABHA shall provide to any OHP Member who requests it the following information:
a. Whether ABHA uses a practitioner incentive plan that affects the use of referral services;
b. The type of incentive arrangement;
c. Whether Stop Loss Coverage is provided; and
d. If a survey is required to ensure access to services is not being denied based on the
practitioner incentive plan, a summary of the survey results.
4. If ABHA practitioner incentive plans meet the definition appearing in Report M.1: Practitioner
Incentive Plan Disclosure, ABHA shall complete and submit to COIHS, on the effective date of
this Agreement and at least 55 calendar days before the effective date of changes to the
practitioner incentive plans, Report M.2: Practitioner Incentive Plan Detail. COIHS will use
information reported to determine whether ABHA incentive arrangements place the practitioner or
practitioner group at risk for amounts beyond a specified risk threshold.
a. Risk threshold means the maximum risk to which a practitioner or practitioner group may
be exposed under a practitioner incentive plan without being at substantial financial risk. It
applies to incentive arrangements involving referral services. The specified risk threshold
is set at 25 percent of potential earnings of the practitioner or practitioner group.
b. Substantial financial risk applies to those practitioners and practitioner groups with a
patient panel size of less than 25,001 OHP Members or a patient panel size of more than
25,000 OHP Members as a result of pooling OHP Members. A substantial financial risk
Effective: January 1, 2011
Exhibit M Page 158 of 221
exists for these practitioners and practitioner groups if the incentive arrangement described
above in 4.a. places the practitioner or practitioner group at risk of losing more than the
risk threshold.
c. An incentive arrangement shall be determined as causing substantial financial risk under
the following circumstances:
(1) Withholds are greater than 25 percent of the maximum anticipated total incentive
payments (salary, FFS payments, Capitation Payments, returned withhold and
bonuses);
(2) Withholds less than 25 percent of potential payments if the practitioner or
practitioner group is potentially liable for amounts exceeding 25 percent of
potential payments;
(3) Bonus that is greater than 33 percent of potential payments minus the bonus;
(4) Withholds plus bonuses if this sum equals more than 25 percent of potential
payments. The threshold bonus percentage for a particular withhold percentage
may be calculated using the formula:
withhold percentage - 0.75(bonus percentage)+25%
(5) For Capitation arrangements, if the difference between the maximum possible
payments and minimum possible payments is more than 25 percent of the
maximum possible payments; or the maximum and minimum possible payments
are not clearly explained in the practitioner's or practitioner group's contract; and
(6) Any other incentive arrangements that have the potential to hold a practitioner or
practitioner group liable for more than 25 percent of potential payments.
5. If ABHA is found to have referral incentive arrangements which place its practitioners or
practitioner groups at substantial financial risk, ABHA shall conduct a survey of OHP Members to
address satisfaction with the quality of services provided and degree of access to the services.
Such survey may be conducted as part of survey administration occurring based on ABHA's QA
Program. ABHA shall provide COIHS with survey data and results within 60 calendar days of the
survey due date. The survey shall:
a. Include either all current OHP Members of COIHS and those who have disenrolled for
reasons other than loss of OHP eligibility or relocation outside the service Areas; or all
those OHP Members enrolled during the past twelve months or a sample of these OHP
Members;
b. Be designed, implemented and analyzed in accordance with commonly accepted principles
of survey design and statistical analysis;
c. Address the satisfaction of OHP Members and disenrolled OHP Members with the quality
of services provided and their degree of access to the services; and
Effective: January 1, 2011
Exhibit M Page 159 of 221
d. Be conducted no later than one year after the effective date of the incentive arrangement
and at least every two years thereafter.
6. ABHA shall ensure that all practitioners and practitioner groups determined to be at substantial
financial risk have either aggregate or per OHP Member Stop Loss Coverage in accordance with
the following requirements:
a. If aggregate Stop Loss Coverage is provided, ABHA shall cover 90 percent of referral
service costs (beyond allocated amounts) that exceed 25 percent of potential earnings of
the practitioner or practitioner group; or
b. If per patient Stop Loss Coverage is provided, ABHA shall provide Stop Loss Coverage
based on patient panel size as reflected in the following table:
Patient Panel Size
Per Patient Stop Loss
Coverage Limit
Less than 1,000
$10,000
1,000 to 10,000
$30,000
10,001 to 25,001
$200,000
More than 25,000 (No Pooling)
No specification
More than 25,000 (Pooling)
$200,000
7. CMS may impose a penalty of up to $25,000 in addition to or in lieu of other remedies available
under law if CMS determines that ABHA either misrepresented or falsified information furnished
to COIHS or an OHP Member in regard to the Practitioner Incentive Plan provisions or failed to
comply with the Practitioner Incentive Plan provisions specified in this Agreement.
8. COIHS will suspend payment for new OHP Members until it is satisfied that the basis for the
determination by CMS is not likely to recur.
Effective: January 1, 2011
Exhibit M – Attachment 1 – Report M.1 Page 160 of 221
Exhibit M – Attachment 1
Report M.1: Practitioner Incentive Plan Disclosure
ABHA Date Prepared:
Signature and Title of Authorized Representative:
Practitioner Incentive Plan: Any incentive arrangement between an eligible organization and a
practitioner or practitioner group that may directly or indirectly have the effect of reducing or
limiting Covered Services furnished with respect to individuals enrolled in the organization. The
compensation arrangement may include a variety of payment methods that create financial
incentives to influence the use of referral services which are arranged, but not directly provided,
by the practitioner subject to the practitioner incentive plan. Such incentive arrangements may
hold a practitioner or a practitioner group at risk for all or a portion of the cost of referral
services and may provide additional compensation to the practitioner or practitioner group if the
practitioner or practitioner group is successful at controlling the level of referral services.
Question or Requirement Response
1. Does said organization use practitioner
incentive plans as defined above for work
performed under this Agreement?
2. If the answer to item 1 is yes, answer these
additional questions.
a. Does the plan reference services that
are not provided by the practitioner
or practitioner group?
b. Does the plan involve a withhold
and/or bonus?
If yes, what is the percent or dollar
amount of the withhold and/or
bonus?
c. Does the plan require Stop Loss
Coverage?
If yes, what type of Stop Loss
Coverage is required?
If yes, what amount of Stop Loss
Coverage is required?
Effective: January 1, 2011
Exhibit M – Attachment 1 – Report M.1 Page 161 of 221
Question or Requirement Response
d. What is the patient panel size?
If the panel size is based on a
pooling of patients, describe the
pooling method used.
e. Does the plan involve Capitation of
practitioners or groups?
If yes, complete the table to the right
using information from the most
recent year.
Practitioner Type Percent of
Total
Capitation
Paid
PCPs
Referral Services to
Specialists
Hospital
Other Types of Providers
Services
Total
f. Does said organization conduct
surveys of OHP Members to
measure the impact of practitioner
incentive plans on quality of
services and access to services?
If yes, when was the last survey
conducted and who was surveyed?
If yes, when will the next survey be
conducted and who will be
surveyed?
If yes, describe how the survey was
designed, implemented and
analyzed.
DHS-OHP-0510-3/98
Effective: January 1, 2011
Exhibit M – Attachment 2 – Report M.2 Page 162 of 221
Exhibit M – Attachment 2
Report M.2: Practitioner Incentive Plan Detail
ABHA Date Prepared:
Provider
Type
Patient
Panel
Size
Service Payments
Incentives
Total
Service
Payments
and
Incentives
Practitioner
Liability
Salary
Fee-for-
Service
Capitation
Total
Bonus
Capitation
Withhold
FFS
Withhold
Referral
Withhold
Total
Primary
Care
Practitioner
s
Referral
Services to
Specialists
Hospital
Other Types
of Providers
Services
Total
Instructions:
1. Provide the total aggregate amount of payment made by ABHA to each provider type by service payment and incentive arrangement
for services delivered under this Agreement during the risk/incentive period.
2. If any one particular referral provider comprises 25% or more of any referral incentive arrangement, then provide the name, address
and phone number of the provider group.
3. Provide a written, signed and dated statement and justification if any of the above information is to be considered confidential.
Effective: January 1, 2011
Exhibit M – Report M.2 - Definitions Page 163 of 221
Other Definitions for Report M.2 – Practitioner Incentive Plan Detail
Bonus: A payment made to a practitioner or practitioner group beyond any salary, FFS
payments, capitation, or returned withhold.
Capitation Withhold: An incentive arrangement where a certain amount is removed from the
negotiated Capitation Payment and might or might not be returned to the Participating Providers
within the health care delivery system to cover a specified set of services and administrative
costs at a given point in time on the basis of certain criteria and/or factors.
Fee-for-Service Withhold: An incentive arrangement where a certain percentage of the service
fee is removed from the base amount of the service fee and might or might not be returned to the
Participating Providers within the health care delivery system on the basis of certain criteria
and/or factors.
Practitioner Liability: An incentive arrangement where payments are made to or by
Participating Providers within the health care delivery system at a given point in time on the
basis of certain performance criteria. Practitioner liability does not include those items defined
elsewhere on this page.
Referral: Any specialty, inpatient, outpatient, or laboratory services that a practitioner or
practitioner group orders or arranges, but does not furnish directly.
Referral Withhold: An arrangement between ABHA and Participating Providers in a health
care delivery system to provide an incentive for that system to take on additional financial
responsibility in covering probable, future expenses incurred from providing referral health care
services to COIHS' OHP Members. These arrangements consist of any amounts ABHA pays
Participating Providers for services provided, including the amounts paid for administration.
These arrangements may control levels or costs of referral services. These payments should only
include arrangements based on referral levels. Arrangements made between ABHA and an
intermediate entity who in turn subcontracts with one or more practitioner groups are to be
reported.
Effective: January 1, 2011
Exhibit N Page 164 of 221
Exhibit N - Grievance System
The purpose of this Exhibit is to describe ABHA’s obligations to create and maintain a Grievance System
consistent with the requirements of 42 CFR 438.400 through 438.424.
1. Grievance System Requirements
a. ABHA shall have written policies and procedures for a Grievance System that ensures
ABHA’s compliance with all regulation requirements, including a grievance process in
accordance with OAR 410-141-0260 through OAR 410-141-0266.
b. ABHA shall submit to COIHS, for review and approval, written Grievance System policies
and procedures, due upon the effective date of this Agreement.
c. ABHA shall provide information to all OHP Members that includes at least:
(1) Written material describing ABHA’s Grievance procedures, and how to make a
Grievance; and
(2) Assurance in all written, oral, and posted material of OHP Member confidentiality
in the Grievance processes.
d. An OHP Member or an OHP Member Representative may file a Grievance orally or in
writing.
e. ABHA shall provide OHP Members with any reasonable assistance in completing forms
and taking other procedural steps related to filing and disposition of a Grievance. This
includes, but is not limited to, providing interpreter services and toll free phone numbers
that have adequate TTY/TTD and interpreter capabilities.
f. ABHA shall keep all information concerning an OHP Member's Grievance confidential, as
specified in OAR 410-141-0261 through 410-141-0264.
g. Consistent with confidentiality requirements, ABHA's staff person who is designated to
receive Grievances shall begin to obtain documentation of the facts concerning the
Grievance upon receipt of the Grievance.
h. ABHA shall afford OHP Members full use of the Grievance System procedures. ABHA
shall cooperate by providing to COIHS, relevant information that may be required for the
Appeal and Administrative Hearing process.
i. Under no circumstances shall ABHA discourage an OHP Member or an OHP Member
Representative from using the Administrative Hearing process.
j. ABHA shall not request Disenrollment of an OHP Member on the basis of implementation
of an Administrative Hearing decision or an OHP Member's request for an Appeal or
Administrative Hearing.
Effective: January 1, 2011
Exhibit N Page 165 of 221
k. ABHA shall make available a supply of blank Grievance forms (OHP 3001) in all ABHA
administrative offices and in those medical offices where staff have been designated by
ABHA to respond to Grievances.
l. ABHA shall provide information about the Grievance System to all Participating Providers
and subcontractors at the time they enter into a contract with ABHA.
m. ABHA shall maintain and submit to COIHS logs that are in compliance with OAR 410-
141-0266 to document Grievances received by ABHA, and ABHA shall review the
information as part of its Quality Improvement strategy.
n. An authorized OHP Member Representative, pursuant to 42 CFR 438.402(b) (ii), may act
for the OHP Member at any stage in the Grievance System. ABHA shall document the
basis on which an individual acts as an OHP Member Representative of the OHP Member.
2. ABHA Grievance Procedures
a. A Grievance procedure applies only to those situations in which the OHP Member or OHP
Member Representative expresses concern or dissatisfaction about any matter other than an
“Action.” As per 42 CFR, 438.408, ABHA shall have written procedures to acknowledge
the receipt, disposition and documentation of each Grievance from OHP Members.
ABHA’s written procedures for handling Grievances, shall, at a minimum:
(1) Address how ABHA will accept, process and respond to each Grievance from an
OHP Member or OHP Member Representative, including:
(a) Acknowledgment to the OHP Member or OHP Member Representative of
receipt of each Grievance.
(b) Ensuring that OHP Members who indicate dissatisfaction or concern are
informed of their right to file a Grievance and how to do so;
(c) Ensuring that each Grievance is transmitted timely to staff who have
authority to act upon it;
(d) Ensuring that each Grievance is investigated and resolved in accordance
with all applicable rules; and
(e) Ensuring that ABHA’s staff person(s) who make decisions on the
Grievance must be persons who are:
(i) Not involved in any previous level of review or decision-making;
and
(ii) Health Care Professionals who have appropriate clinical expertise in
treating the OHP Member’s condition or disease, if the Grievance
concerns denial of expedited resolution of an Appeal or if the
Grievance involves clinical issues; and
(iii) qualified to make denials based on lack of medical necessity.
Effective: January 1, 2011
Exhibit N Page 166 of 221
(2) Describe how ABHA informs OHP Members, both orally and in writing, about
ABHA’s Grievance procedures;
(3) Designate ABHA’s staff member(s) or a designee who shall be responsible for
receiving, processing, directing, and responding to Grievances; and
(4) Include a requirement for Grievances to be documented in the log to be maintained
by ABHA in a manner that is consistent with OAR 410-141-0266.
b. ABHA shall assure OHP Members that Grievances are handled in confidence consistent
with Exhibit D, Section 13.d of this Agreement and with ORS 411.320, 42 CFR 431.300 et
seq, the HIPAA Privacy Rules, the Oregon counterpart of HIPAA Privacy Rules at ORS
192.518 to 192.524, and other applicable federal and state confidentiality laws and
regulations. ABHA shall safeguard the OHP Member’s right to confidentiality of
information about the Grievance as follows:
(1) ABHA shall implement and monitor written policies and procedures to ensure that
all information concerning an OHP Member’s Grievance is kept confidential,
consistent with appropriate use or disclosure as Treatment, payment, or health care
operations of ABHA, as those terms are defined in 45 CFR 164.501 and ORS
192.519. As specified in OAR 410-141-0261 (3)(a), ABHA and any Provider
whose Services, items or Quality of Care is alleged to be involved in the Grievance
have a right to use this information for purposes of ABHA resolving the Grievance,
for purposes of maintaining the log required in OAR 410-141-0266, and for health
oversight purposes, without a signed authorization from the OHP Member; and
(2) Except as provided in Paragraph (1) of this Subsection c, or as otherwise permitted
by all other applicable confidentiality laws, ABHA shall ask the OHP Member to
authorize a release of information regarding the Grievance to other individuals as
needed for resolution. Before any information related to the Grievance is disclosed
under this subsection, ABHA shall have an authorization for release of information
documented in the Grievance file. Copies of the form for authorizing the release of
information shall be included in ABHA’s written process.
c. ABHA’s procedures shall provide for the disposition of Grievances within the following
timeframes:
(1) ABHA shall resolve each Grievance, and provide notice of the disposition, as
expeditiously as the OHP Member’s health condition requires, within the
timeframes established below;
(2) For standard disposition of Grievances and notice to the affected parties, within 5
working days from the date of ABHA’s receipt of the Grievance, ABHA shall
either:
(a) Make a decision on the Grievance and notify the OHP Member; or
(b) Notify the OHP Member in writing that a delay in ABHA’s decision, of up
to 30 calendar days from the date the Grievance was received by ABHA, is
Effective: January 1, 2011
Exhibit N Page 167 of 221
necessary to resolve the Grievance. The written notice shall specify the
reasons the additional time is necessary.
d. ABHA's decision about the disposition of a Grievance shall be communicated to the OHP
Member orally or in writing within the timeframes specified in Section 2, Subsection d of
this Exhibit:
(1) An oral decision about a Grievance shall address each aspect of the OHP Member’s
Grievance and explain the reason for ABHA's decision;
(2) A written decision must be provided if the Grievance was received in writing. The
written decision on the Grievance shall review each element of the OHP Member’s
Grievance and address each of those concerns specifically, including the reasons
for ABHA’s decision.
e. All Grievances made to ABHA’s staff person designated to receive Grievances shall be
entered into a log and addressed in the context of Quality Improvement activity (OAR 410-
141-0200) as required in OAR 410-141-0266.
f. All Grievances that the OHP Member chooses to resolve through another process, and that
ABHA is notified of, shall be noted in the Grievance log.
g. An OHP Members who is dissatisfied with the disposition of a Grievance may present the
Grievance to COIHS or the DHS’ Governor’s Advocacy Office.
(1)
3. Notice of Action
a. When ABHA (or authorized subcontractor or Participating Provider acting on behalf of
ABHA) takes or intends to take any Action (including, but not limited, to denials or
limiting prior authorizations of a requested Covered Service(s) in an amount, duration, or
scope that is less than requested, or reductions, suspension, discontinuation or termination
of a previously authorized Service), ABHA (or authorized subcontractor or Participating
Provider acting on behalf of ABHA) shall mail a written Notice of Action in accordance
with Section 3, Subsection b of this Exhibit to the OHP Member within the timeframes
specified in Section 3, Subsection c of this Exhibit.
b. The written Notice of Action must be a DHS approved format and it must be used for all
denials of a requested Covered Service(s), reductions, discontinuations or terminations of
previously authorized Covered Services, denials of claims payment, or other Action. The
Notice of Action must meet the language and format requirements in Exhibit Q, entitled
“Informational Materials and Education of OHP Members and Potential OHP Members,”
and must inform the OHP Member of the following:
(1) Relevant information including, but not limited to, the following:
(a) Date of Notice of Action;
(b) ABHA’s name;
Effective: January 1, 2011
Exhibit N Page 168 of 221
(c) Provider name;
(d) OHP Member’s name and ID number;
(e) Date of Service or item requested or provided;
(f) Who requested or provided the item or Service; and
(g) Effective date of the Action.
(2) The Action ABHA or its subcontractor or Participating Provider has taken or
intends to take;
(3) Reasons for the Action, including, but not limited to, the following reasons:
(a) Treatment is not a Covered Service;
(b) The item requires pre-authorization and it was not pre-authorized;
(c) The Service is not Medically Appropriate;
(d) The Service or item is received in an emergency care setting and does not
qualify as an Emergency Service;
(e) The person was not an OHP Member at the time of the Service or is not an
OHP Member at the time of a requested Service; or
(f) The Provider is not on ABHA’s panel and prior approval was not obtained
(if such prior authorization would be required under the Oregon Health Plan
Rules).
(4) A reference to the particular sections of the statutes and administrative rules
involved for each reason identified in the Notice of Action pursuant to Section 3,
Subsection b, of this Exhibit;
(5) The OHP Member’s right to file an Appeal or Administrative Hearing with COIHS
and how to exercise that right as required in OAR 410-141-0262;
(6) The circumstances under which expedited Appeal resolution is available and how
to request it;
(7) The OHP Member’s right to have benefits continue pending resolution of the
Appeal or Administrative Hearing, how to request that benefit(s) be continued, and
the circumstances under which the OHP Member may be required to pay the costs
of these Services; and
(8) The telephone number to contact ABHA or COIHS for additional information.
Effective: January 1, 2011
Exhibit N Page 169 of 221
c. ABHA or subcontractor or Participating Provider(s) acting on behalf of ABHA shall mail
the Notice of Action within the following time frames:
(1) For termination, suspension, or reduction of previously authorized Covered
Services, the following time frames apply:
(a) The notice must be mailed at least 10 calendar days before the date of
Action, except as permitted under Section 3, Subsections c, Paragraph (1),
Items (b) or (c) of this Exhibit;
(b) ABHA (or authorized subcontractor or Participating Provider acting on
behalf of ABHA) may mail a notice not later than the date of Action if:
(i) ABHA, subcontractor or Participating Provider receives a clear
written statement signed by the OHP Member that he or she no
longer wishes Services or gives information that requires
termination or reduction of Services and indicates that he or she
understands that this must be the result of supplying the information;
(ii) The OHP Member has been admitted to an institution where he or
she is ineligible for Covered Services from ABHA;
(iii) The OHP Member’s whereabouts are unknown and the post office
returns ABHA, subcontractor or Participating Provider’s mail
directed to him or her indicating no forwarding address;
(iv) ABHA establishes the fact that another state, territory, or
commonwealth has accepted the OHP Member for OHP Services;
(v) There is a change in the level of medical care that is prescribed by
the OHP Member’s Provider;
(vi) The date of Action will occur in less than 10 calendar days, in
accordance with 42 CFR 483.12(a)(5), related to discharges or
transfers and long-term care facilities;
(vii) There is factual information confirming the death of the OHP
Member;
(viii) There is an adverse determination made with regard to the
preadmission screening requirements for Nursing Facility
admissions; or
(ix) The safety or health of individuals in the facility would be
endangered, the OHP Member’s health improves sufficiently to
allow a more immediate transfer or discharge, an immediate transfer
or discharge is required by the OHP Member’s urgent medical
needs, or an OHP Member has not resided in the Nursing Facility
for 30 days (applies only to adverse actions for Nursing Facility
transfers).
Effective: January 1, 2011
Exhibit N Page 170 of 221
(c) ABHA may shorten the period of advance notice to 5 calendar days before
the date of the Action if ABHA has facts indicating that an Action should
be taken because of probable fraud on the part of the OHP Member.
Whenever possible, these facts should be verified through secondary
sources.
(1) For denial of payment, at the time of any Action affecting the claim;
(2) For standard prior authorizations that deny a requested Service or that authorize a
Service in an amount, duration, or scope that is less than requested, ABHA shall
provide Notice of Action as expeditiously as the OHP Member’s health condition
requires and within 14 calendar days following receipt of the request for Service,
except that:
(a) ABHA may have a possible extension of up to 14 additional calendar days
if the OHP Member or the Provider requests the extension; or if ABHA
justifies (to DHS or COIHS upon request) a need for additional information
and how the extension is in the OHP Member’s interest;
(b) If ABHA extends the timeframe, in accordance with Section 4, Subsection
c, Paragraph (3), Item (a) of this Exhibit, it shall give the OHP Member
written notice of the reason for the decision to extend the timeframe and
inform the OHP Member of the right to file a Grievance if he or she
disagrees with that decision. ABHA shall issue and carry out its prior
authorization determination as expeditiously as the OHP Member’s health
condition requires and no later than the date the extension expires.
d. For prior authorization decisions not reached within the timeframes specified in Section 3,
Subsection c, Paragraph (3) of this Exhibit, (which constitutes a denial and is thus an
adverse Action), on the date that the timeframes expire;
e. For expedited prior authorizations, within the timeframes specified in OAR 410-141-0265.
4. ABHA Responsibilities in Relations to Appeals
a. If an OHP member files an appeal directly with ABHA, ABHA will immediately (within 1
business day) forward the request to COIHS in the most expeditious way possible (such as
fax) to ensure timely action by COIHS.
b. Upon request by COIHS G&A staff, ABHA will forward requested documentation, such
as medical records, notices of action and/or explanation of benefits to staff within the
timeframe specified in the request.
5. ABHA Responsibilities in Relation to AMH Administrative Hearings
a. An individual who is or was an OHP Member at the time of the Notice of Action is entitled
to an Administrative Hearing by AMH if ABHA that has denied requested services,
payment of a claim, or terminates, discontinues or reduces a course of treatment, or any
other Action.
Effective: January 1, 2011
Exhibit N Page 171 of 221
(1) If the OHP Member initiates an Administrative Hearing directly with AMH, the
decision in the Notice of Action is the document that will trigger the right to
request a Administrative Hearing.
(2) If the OHP Member requests an Administrative hearing after receiving a Notice of
Appeal Resolution, the decision in the Notice of Appeal Resolution is the document
that will trigger the right to request a state administrative hearing.
b. If, at the OHP Member’s request for an Appeal or Administrative Hearing, ABHA
continued or reinstated Services while the Appeal was pending, the benefits must be
continued pending the Administrative Hearing until one of the following occurs:
(1) The OHP Member withdraws the request for an Administrative Hearing;
(2) A final order is issued in an Administrative Hearing adverse to the OHP Member;
or
(3) The time period or Service limits of a previously authorized Service have been met.
c. If the OHP Member files an Administrative Hearing Request form (DHS 0443) with
ABHA, BHA shall immediately transmit the request to COIHS.
d. If the OHP Member files an Administrative Hearing Request form (DHS 0443) with DHS,
DHS will promptly (within two (2) business days) send a copy of the Administrative
Hearing Request form, to COIHS, and ask COIHS to treat it as an Appeal in accordance
with Section 3 of this Exhibit.
e. The AMH Hearings Unit shall review each Administrative Hearing Request,
documentation related to the Administrative Hearing, and computer records to determine
whether the claimant or the person for whom the request is being made is or was an OHP
Member at the time the Action was taken, whether the Administrative Hearing request was
timely, and whether benefit continuation has been timely requested. If the AMH Hearings
Unit finds that the person for whom the review request was made is not an OHP Member
or that the Administrative Hearing request was untimely or that a request for continuation
of benefit was untimely, the AMH Hearings Unit follow the process described in OAR
410-120-1860(4).
f. The AMH Hearings Unit will refer the case to the Office of Administrative Hearings and
the hearing will be scheduled unless the OHP Member withdraws the request for review.
(1) The parties to the hearing include COIHS and ABHA, as well as the OHP Member
and the OHP Member Representative, or the Representative of a deceased OHP
Member’s estate.
(2) The procedures applicable to the hearing shall be conducted consistent with OAR
410-120-1865.
(3) A final order should be issued or the case otherwise resolved by DHS ordinarily
within 90 calendar days from the earlier of the following: the date the OHP
Effective: January 1, 2011
Exhibit N Page 172 of 221
Member filed the Appeal request form with COIHS and/or ABHA or the date the
OHP Member filed the Hearing Request form. The final order is the final decision
of DHS.
g. If the final resolution of the Administrative Hearing is adverse to the OHP Member, that is,
if the final order upholds ABHA’s Action, ABHA may recover the cost of the Services
furnished to the OHP Member while the Administrative Hearing is pending, to the extent
they were furnished solely because of the requirements of this section, and in accordance
with the policy set forth in 42 CFR 438.420.
f. ABHA shall promptly correct the Action taken up to the limit of the original request or
authorization, retroactive to the date the Action was taken, if the Administrative Hearing
decision is favorable to the OHP Member, or DHS or COIHS or ABHA decides in the
OHP Member’s favor before the Administrative Hearing even if the OHP Member has lost
OHP eligibility or the benefit package has changed after the date the Action was taken,
including the following:
(1) If ABHA, COIHS, or an Administrative Hearing decision reverses a decision to
deny, limit, or delay Services that were not furnished while the Administrative
Hearing was pending, ABHA shall authorize or provide, and shall pay for, the
disputed Services promptly, and as expeditiously as the OHP Member’s health
condition requires;
(2) If ABHA, COOIHS, or the Administrative Hearing decision reverses a decision to
deny authorization of Services, and the OHP Member received the disputed
Services while the Administrative Hearing was pending, ABHA shall pay for the
Services in accordance with AMH policy and regulations in effect when the OHP
Member made the request for Services.
6. ABHA’s Responsibility for Documentation and Quality Improvement Review of the
Grievance System
a. ABHA’s documentation shall include, at minimum, a log of all oral and written Grievances
received by ABHA. The log shall identify the OHP Member and the following additional
information:
(1) For Grievances, the date of the Grievance, the nature of the Grievance, the
disposition and date of disposition of the Grievance.
b. ABHA shall also maintain a record, in a central location for each of the Grievances
included in the log. The record shall include records of the review or investigation and
resolution, including all written decisions and copies of correspondence with the OHP
Member. ABHA shall retain documentation of Grievances for 7 (years) to permit
evaluation. This requirement survives the termination or expiration of this Agreement.
c. ABHA shall have written procedures for the review and analysis of the Grievance System,
including all Grievances received by ABHA. The analysis of the Grievance System shall
be forwarded to the Quality Improvement committee as necessary to comply with the
Quality Improvement standards:
Effective: January 1, 2011
Exhibit N Page 173 of 221
(1) ABHA shall monitor the completeness and accuracy of the written log, on a
monthly basis; and
(2) ABHA’s monitoring of Grievances shall include, at minimum, review of
completeness, accuracy, timeliness of documentation, and compliance with written
procedures for receipt, disposition, and documentation of Grievances, and
compliance with OHP rules.
Effective: January 1, 2011
Exhibit N – Attachment 1 Page 174 of 221
Exhibit N – Attachment 1 - Grievance Log
1. Grievance means an oral or written communication, submitted by an OHP Member or an OHP Member
Representative, which addresses issues with any aspect of ABHA’s or Provider’s operations, activities,
or behavior that pertains to 1) the availability, delivery, or Quality of Care, including Utilization review
decisions, that are believed to be adverse by the OHP Member; or 2) the denial, reduction, or limitation
of Covered Services under this Agreement. The expression may be in whatever form or communication
or language that is used by the OHP Member or the OHP Member Representative, but must state the
reason for the dissatisfaction and the OHP Member’s desired resolution.
2. An OHP Member, or OHP Member Representative, may relate any incident or concern to ABHA,
Provider, or subcontractor, by indicating or expressing dissatisfaction or concern, or by stating this is a
Grievance that needs resolution.
3. Grievances are a source of information that may be used to evaluate the quality of access, Provider
service, clinical care, or ABHA’s Service to OHP Members. ABHA shall have written policies and
procedures for the thorough, appropriate and timely resolution of OHP Member Grievances, which
include:
a. Documentation of the nature of the Grievance which shall include, at minimum:
(1) A log of formal Grievances;
(2) A file of written formal Grievances, and
(3) Records of their resolution.
b. Analysis and investigation of the Grievance; and
c. Notification to the OHP Member of the disposition of the Grievance and the OHP Member’s
right to Appeal the outcome of the Grievance or handling of a Grievance.
4. ABHA shall complete and submit the Grievance Log on a quarterly basis within 45 calendar days of the
end of each calendar quarter. ABHA shall record each Grievance once on the Grievance Log. If the
Grievance covers more than one category, BHA shall record the Grievance in the predominant category.
5. ABHA shall send the Grievance Log to COIHS.
6. If ABHA has questions about this report, Contractor may call COIHS.
Effective: January 1, 2011
Exhibit N – Attachment 1 Page 175 of 221
2011 OHP MHO Contract – Effective January 1, 2011 -
Grievance Log
ABHA Year:_______________
Report Period (circle): Jan-Mar Apr-Jun Jul-Sep Oct-Dec
Grievance: An oral or written communication, submitted by an OHP Member or an OHP Member Representative, which addresses issues with any
aspect of ABHA’s or Provider’s operations, activities, or behavior that pertains to the availability, delivery, or Quality of Care including Utilization
review decisions that are believed to be adverse by the OHP Member. The expression may be in whatever form or communication or language that is
used by the OHP Member or the OHP Member Representative, but must state the reason for the dissatisfaction and the OHP Member’s desired
resolution.
Client/Rep
Identifier *1
Date
Received
Grievance
Type *2
Disposition: Select One - Resolved / Appeal
Requested / Hearing Requested
Disposition Date # Days to
Disposition *3
*1: ABHA/subcontractor must track client/representative identity, but may choose not to include identifier in submitted Grievance logs.
*2: A=Access D=Denial of Service, Authorization or Payment C=Clinical Care
I=Interaction with Provider, ABHA or Staff Q=Quality of Service CR=Consumer Rights
*3: Count of calendar days begins with the receipt date and does not include the final date of disposition. (For example, if a Grievance is received
Thursday, January 4, 2011 and disposed of Tuesday, January 9, 2011, the # of calendar days would be 5-days).
This document is not all inclusive of the monitoring/tracking responsibilities related to Grievances of ABHA.
Exhibit O Page 176 of 221
Exhibit O – Reserved
Exhibit P Page 177 of 221
Exhibit P – Additional Subcontractor Requirements
ABHA must oversee and is accountable for any functions and responsibilities that it subcontracts
to any subcontractor as specified in 42 CFR 438.230. Subject to the provisions of this section,
ABHA may specify subcontracted work to be performed under this Agreement. No subcontract
shall terminate or limit ABHA’s legal responsibility to COIHS for the timely and effective
performance of its duties and responsibilities under this Agreement. The requirements of this
section do not prevent ABHA from including additional terms and conditions in its subcontracts
to meet the legal obligations or system requirements of ABHA.
1. ABHA shall evaluate the prospective subcontractor’s ability to perform the activities to
be subcontracted, prior to subcontracting.
2. ABHA shall have a written agreement that specifies the subcontracted activities and
reporting responsibilities of the subcontractor.
3. ABHA’s agreement with the subcontractor shall provide for the revocation of the
subcontract or imposition of other sanctions if the subcontractor’s performance is
inadequate to meet the requirements of this Agreement.
4. ABHA shall monitor subcontractor’s performance for contractual compliance on an
ongoing basis. Upon identification of areas of deficiency ABHA shall require of the
subcontractor, a COIHS approved Corrective Action Plan, as defined in Exhibit A of this
Agreement. The Corrective Action Plan shall provide the following information:
a. Reason(s) for the Corrective Action Plan;
b. Effective date of the Corrective Action Plan;
c. Required resolution of the area(s) of concern; and
d. Intended remedies short of termination should the subcontractor not come into
compliance within the required timeframe.
Upon notification of the subcontractor, ABHA shall also provide notification to COIHS outlining
information as stated in this section.
5. All subcontracts shall meet the requirements described below and shall incorporate
portions of this Agreement, as applicable, based on the scope of work to be
subcontracted. All subcontracts shall meet the following requirements:
a. Be in writing and incorporate each applicable requirement of this Agreement,
including the following: Exhibit B, Part V, Section 1, Recordkeeping; Exhibit D,
Section 8, Indemnification; Section 9, Termination, and Section 19, Amendments;
Exhibit E, Required Federal Terms and Conditions; and every other provision in
this Agreement that sets requirements for any of the activities being
subcontracted.
Exhibit P Page 178 of 221
b. Clearly identify work to be performed by the subcontractor and what portion of
that work, if any, the subcontractor may further subcontract.
c. Ensure that the requirements of 42 CFR Part 438 that are appropriate to the
Services or activities required under the subcontract are fulfilled.
d. Contain a provision that the subcontractor and referral Providers shall not bill,
charge, seek compensation, remuneration or reimbursement from, or have
recourse against DHS or any OHP Member for Covered Services provided during
the period for which Capitation Payments were made by DHS to ABHA, via
COIHS, with respect to said OHP Member, even if ABHA becomes insolvent.
Subcontractors and referral Providers may not bill OHP Members any amount
greater than would be owed by the OHP Member if ABHA provided the services
directly (i.e., no balance billing by Providers).
e. Contain a provision that the subcontractor shall continue to Provide Covered
Services during periods of ABHA insolvency or cessation of operations through
the period for which Capitation Payments were made to ABHA.
f. Contain a provision requiring the subcontractor to follow OAR 410-141-0420,
Billing and Payment Under the Oregon Health Plan, when submitting FFS claims
for Oregon Health Plan Services provided to OHP Members that are not Covered
Services.
g. Contain a provision requiring Subcontractors to comply with OAR 410-120-1230,
Client Copayment, applicable only to OHP Members eligible for the OHP Plus
Benefit Package.
h. Contain a provision that describes billing and payment processes for all
subcontracted services and activities.
i. Contain a provision that requires Subcontractor to maintain the appropriate
Professional Liability minimum insurance limits (1 million each occurrence and 3
million in the aggregate) as set forth by industry standards.
j. In cases where the subcontractor has assumed any risk covered under this
Agreement, contain a provision that the subcontractor must protect itself against
loss by either self-insuring or providing proof of Reinsurance and by maintaining
a Restricted Reserve Fund as described in Exhibit G, Solvency Plan and Financial
Reporting.
k. If ABHA is contracting with Federally Qualified Health Clinics (FQHCs) and
Rural Health Clinics (RHC’s) ABHA shall provide payment that is not less than
the level and amount of payment which the Contractor would make for the same
Exhibit P Page 179 of 221
service(s) furnished by a Provider, which is not an FQHC or RHC consistent with
the requirements for 42 USC 1396b (m) (2)(A)(ix) and BBA 4712(b)(2).
l. If ABHA chooses to subcontract the Grievance Process, ABHA shall require the
subcontractor to have written policies and procedures for accepting, processing
and responding to all Grievances from Family Members, Allied Agencies, and
OHP Members consistent with Exhibit N, Grievance System.
m. Contain a provision that data used for analysis of delivery system Capacity,
Consumer satisfaction, financial solvency, and Encounter, client process
monitoring, and Acute Inpatient Hospital Psychiatric Care admission data
submission must be provided to ABHA to meet reporting requirements described
in Exhibit K, Provider Capacity Assurance Report; Exhibit N, Attachment 1
Grievance Log; Exhibit G, Solvency Plan and Financial Reporting; Schedule 1,
Client Process Monitoring System; and Schedule 3, Oregon Patient/Resident Care
System.
n. 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 OHP Members.
o. Contain a provision that requires the subcontractor to participate in Quality
Assessment and Quality Improvement activities of ABHA and/or COIHS, or
those of AMH if requested to do so.
p. 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, Exhibit B, Part V, Section 1, Recordkeeping and
Exhibit B, Part VI, Section 1, AMH Compliance Review and Quality Assurance
Monitoring and to cooperate with AMH in medical and financial record reviews,
and Contract compliance and QA monitoring.
q. Subcontractors shall submit all marketing materials to AMH for review and
approval prior to circulation.
r. Contain a provision that requires the subcontractor to cooperate with all processes
and procedures of Abuse reporting, investigations, and protective Services as
described in ORS 430.735 through 430.765, Abuse Reporting for Mentally Ill and
OAR 410-009-0050 through 410-009-0160, Abuse Reporting and Protective
Services in Community Programs and Community Facilities.
s. If ABHA chooses to subcontract Utilization Management activities, ABHA shall
assure that compensation to Providers is not structured so as to provide incentives
to deny, limit or discontinue Medically Appropriate services to OHP members.
Exhibit P Page 180 of 221
6. On the effective date of this Agreement, ABHA shall submit Schedule 9 to COIHS in
writing specifying the activities subcontracted and the entities performing such
subcontracted activities. ABHA shall notify COIHS by resubmitting Schedule 9 of
changes in subcontracted activities within 15 calendar days of such change(s).
Exhibit Q Page 181 of 221
Exhibit Q - Informational Materials and Education of OHP Members
Handbook Review Document
OHP Members shall receive OHP Member Handbooks. Distribution shall occur within 14
calendar days of the OHP Member’s effective date of coverage with COIHS. OHP Member
handbooks shall incorporate the elements included this Agreement. ABHA shall review the
OHP Member handbook for accuracy at least yearly, updating with new or corrected information
as needed to reflect ABHA’s internal changes and any regulatory changes; provided, however,
that such review shall pertain only to those sections of the OHP Member Handbook where
ABHA is involved and/or provides services.
Date:
Mental Health Organization:
Status of Document:
□ Approved
□ Approved with Changes
□ Not Approved, Revise and Resubmit
□ Approved by Agency Date: _____________
References: MHO Contract, Exhibit B, Part III, 1, OAR 410-141-0300 and 42 CFR 438.10
Evaluation of copies submitted to COIHS for review and approval shall include the following
elements:
Item
Number
Page
Number
in
Handbook
Requirement
Item
Approved
Yes No
AMH
Comments
1 6th Grade language, 12 point font, sentences
25 words or less in length
2
Tag line translation in all required languages
(should be located in the front portion of the
handbook)
5 How to use the appointment system
6 How to access interpreter services
7
Telephone number, including
TTY/TDD/Oregon Relay, for gathering more
information on the topics listed below.
8
How OHP Members choose and use
Providers, including; ABHA office
addresses, hours of operation, availability of
adaptations for OHP Members with
disabilities and ADA compliance and non-
English languages by current contracted
providers in the OHP Member’s service area.
Information should include hospitals.
9 Any restrictions on the OHP Member’s
freedom of choice among network Providers.
Exhibit Q Page 182 of 221
Item
Number
Page
Number
in
Handbook
Requirement
Item
Approved
Yes No
AMH
Comments
10 Explanation of Covered and Non-Covered
Services and how to access those services.
15
How to obtain mental health prescription
medication.
16
Urgent/Emergent Care and how after-hours
and emergency coverage are provided ,
including:
a. What constitutes an emergency and
use of 911;
b. Specify layperson language re:
emergencies;
c. The fact that prior authorization is
not required for emergency services;
d. How to access urgent care services
and advice;
e. Crisis Services;
f. Urgent and Emergent care away from
home;
g. Post-stabilization services, with
reference to the definitions in 42
CFR Section 438.114 (a);
h. The locations of any emergency
settings and other locations at which
providers and hospitals furnish
emergency services and post-
stabilization care services covered
under the contract and 42 CFR
Section 422.113 ( c ) and as related to
Emergency Medical Condition that
are provided after an OHP Member is
stabilized in order to maintain the
stabilized condition or under the
circumstances to improve or resolve
the OHP Member’s condition.
i. Member’s possible responsibility for
charges, including Medicare
deductibles and coinsurance if they
go outside of the Plan for non-
emergent care and charges for Non-
Covered Services
17 Use of the referral system, including what
Exhibit Q Page 183 of 221
Item
Number
Page
Number
in
Handbook
Requirement
Item
Approved
Yes No
AMH
Comments
services must be preauthorized and how to
obtain a referral
18
How to obtain copies of OHP Member
records, including whether ABHA charges
for copying.
21
Declaration of Mental Health Treatment in
accordance with ORS 127.703 or other
applicable law, specify how this is handled
within your plan.
23
Grievance System Information:
Grievance, Appeal and Fair Hearing
procedures and timeframes, as provided in
42 CFR Section 438.400 – 438.424.
Provide a State approved description
including the following:
a) The right to file grievances, appeals
and administrative hearings;
b) The toll-free numbers that the OHP
Member can use to file a grievance or
appeal by phone;
c) The requirements and timeframes in
the filing process for grievances and
appeals
d) The availability of assistance in the
filing process;
e) The method of obtaining a hearing;
f) The rules that govern representation
at the hearing
g) The fact that when requested by the
OHP Member;
1. Benefits will continue if the
OHP Member files an appeal
or a request for State Fair
Hearing within the
timeframes specified for
filing; and
2. The OHP Member may be
required to pay the cost of
services furnished while the
appeal is pending, if the final
Exhibit Q Page 184 of 221
Item
Number
Page
Number
in
Handbook
Requirement
Item
Approved
Yes No
AMH
Comments
decision is adverse to the
enrollee.
b. Appeal rights available to providers
to challenge the failure of the
organization to cover a service
Glossary: Define the following terms, using CFR language supplied
Action - Action means-In the case of the MCO or PIHP-
(1) The denial or limited authorization of a requested service, including the type or level of
service;
(2) The reduction suspension or termination of a previously authorized service;
(3) The denial, in whole or in part, of payment for a service;
(4) The failure to provide services in a timely manner; as defined by the State; (5)The failure
of an MCO or PIHP to act within the timeframe provided in 438.408 (b); or
(6) For a resident of a rural area with only one MCO, the denial of a Medicaid enrollee’s
request to exercise his or her services outside the network.
Appeal - means a request for review of an action as “action” is defined in 42 CFR 438.400 (and
in this listing).
Crisis Services
Emergency Medical Condition - means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses
an average knowledge of health and medicine, could reasonably expect the absence of immediate
medical attention to result in the following:
(1) Placing the health of the individual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy.
(2) Serious impairment to bodily functions.
(3) Serious dysfunction of any bodily organ or part.
Emergency Services – Covered in-patient and outpatient services that are as follows:
(1) Furnished by a provider that is qualified to furnish these services under this title.
(2) Needed to evaluate or stabilize an emergency medical condition.
Excluded Services - Certain services or items are not covered under any program or for any
group of eligible Clients. If the Client accepts financial responsibility for a
Non-Covered Service, payment is a matter between the Provider and the
Client subject to the requirements of OAR 410-120-1280.
Grievance - Grievance means an expression of dissatisfaction about any matter other than an
action, as defined in CFR.
Exhibit Q Page 185 of 221
Post-Stabilization Care Services – means covered services, related to an emergency medical
condition that are provided after an enrollee is stabilized in order to maintain the stabilized
condition, or, under the circumstances described in CFR 438.114 (e) to improve or resolve the
enrollee’s condition.
Service Area - The geographic area the Contractor has identified in their Contract or Agreement
with DHS, to provide services under the OHP.
Urgent Care - means calling for haste, immediate action.
Effective: January 1, 2011
Schedule 1 Page 186 of 221
Schedule 1 – Client Process Monitoring System (CPMS)
The CPMS tracks community-based treatment services for persons with mental illness, persons
with developmental disabilities, and persons with substance abuse problems. Information from
this system is combined with other information from other systems to create one integrated
database under a single unique client identifier. The integrated database contains Consumer
specific data across programs statewide and provides a Continuity of Care picture for individual
Consumers. This information allows AMH to manage publicly funded mental health services,
respond to legislative inquiries, and demonstrate cost effectiveness under the federal requirement
for the OHP.
ABHA shall assure submission of CPMS data for OHP Members consistent with the CPMS
Manual Instructions.
Effective: January 1, 2011
Schedule 1 Page 187 of 221
Data Element
Treatment Begin
Treatment
End
Reported Quarterly
Client County of Residence
X
Clinic or Service Provider
X
Date of Birth
X
Diagnosis
X
X
Education
X
Employment Status
X
Gender
X
Level of Functioning
X
X
X
Living Arrangement
X
MHIS Number
X
Name, Birth
X
Name, Full
X
Plan or Contractor Identifier
X
Presenting Dangers
X1
Prime Number
X
Provider or Clinic Case No.
X
Race/Ethnicity
X
Referred From
X
Termination Referral
X
Termination Type/Reason
X
Data element to be reported upon end of Urgent/Emergency Service only.
Effective: January 1, 2011
Schedule 2.1 Page 188 of 221
Schedule 2.1 – Procedure for Long Term Psychiatric Care Determinations for OHP Members 18 to 64
Actor Action
ABHA
1. Determines whether the situation of the OHP Member meets both of
the following criteria:
a. Diagnosis has been determined based on criteria from the
latest version of the Diagnostic and Statistical Manual of
Mental Health Disorders and Medically Appropriate treatment
has been provided according to American Psychiatric
Association provision of care guidelines for that diagnosis,
b. There is a need for either Intensive Psychiatric Rehabilitation
or other Tertiary Treatment in a State Hospital or Extended
Care Program, or Extended and Specialized Medication
Adjustment (psychotropic) in a secure or otherwise highly
supervised environment; and the individual has been
determined to meet AMH established criteria for long-term
psychiatric care admission, and
c. The OHP Member has received all Usual and Customary
Treatment including, if Medically Appropriate, establishment
of a medication program and use of a Medication Override
Procedure.
2. If the situation of the OHP Member meets the criteria listed above in
step 1, does the following with assistance from Acute Inpatient
Hospital Psychiatric Care or Subacute Psychiatric Care or Other
Inpatient Services staff:
a. Contacts the AMH ECMU Long Term Care Coordinator at
(503) 947-5542, during normal business hours (Monday
through Friday, 8 a.m. to 5 p.m.).
b. Completes a Request for LTPC Determination for Persons
Age 18 to 64 (request form).
c. Obtains the following documents:
(1) Physician's history and physical;
(2) Copies of legal documents (hospital hold, commitment
paperwork or appoint of guardian);
(3) Current medications, dosages, and length of time on
medication;
(4) Reports of other Consultations;
(5) Psychosocial histories; and
Effective: January 1, 2011
Schedule 2.1 Page 189 of 221
Actor Action
ABHA (continued) (6) Current week's physician and progress notes.
3. Sends, by facsimile, the request form and supporting documents to
the AMH ECMU Screener at (503)947-5542, Attention: ECMU
Long Term Care Coordinator.
ECMU Long Term Care
Coordinator
4. Within three working days of receiving a completed request form,
does the following:
a. Reviews the request form and documentation for compliance
with criteria for LTPC with the following facilities:
(1) OSH, Portland Campus;
(2) OSH, Salem Campus;
(3) Blue Mountain Recovery Center;
(4) Efficacious alternatives in the community.
b. If necessary, visits the Acute Care Inpatient Hospital Care or
Subacute Care or Other Inpatient Psychiatric Services facility
to interview staff and the OHP Member.
c. Indicates determination and, if authorized for LTPC, the date
of authorization on the form.
d. Discuss findings, determination and placement alternatives
with ABHA.
5. Sends, by facsimile, the completed request form including
determination and rationale to ABHA.
ABHA
6. If the OHP Member does not meet LTPC criteria and is denied
services or if the OHP Member is found appropriate for LTPC but on
a date other than that specified in Exhibit B, Part II, Section 1,
Subsection c, Paragraph (10) (c) (i) of this Agreement, ABHA shall
do one of the following:
a. Agree with the ECMU Long Term Care Coordinator’s
decision and provide appropriate Treatment or initiates
transfer of the OHP Member to a Setting recommended as of
the specified date; or
b. Disagree with the ECMU Long Term Care Coordinator’s
decisions and requests an expedited clinical review within
three working days of the denial. This request must be in
writing and contain documentation in accordance with Step
2.c. of this Section to AMH via facsimile at (503) 378-8467.
Effective: January 1, 2011
Schedule 2.1 Page 190 of 221
Actor Action
AMH 7. If ABHA requests a clinical review, sends, by facsimile, the request
form and documentation submitted by ABHA in accordance with
Step 2.c. of this Exhibit to the Clinical Reviewer.
Clinical Reviewer
8. Does the following within three working days of receiving the
clinical review packet:
a. Reviews all documentation submitted by ABHA in
accordance with Step 2.c. of this Exhibit.
b. Decides whether the OHP Member is appropriate for LTPC.
c. Determines the effective date of LTPC as specified in Exhibit
B, Part II, Section 1, Subsection c, Paragraph (10) (c) of this
Agreement, if applicable.
d. Updates the request form.
e. Notifies, by phone, ABHA and/or COIHS, AMH and the
ECMU Long Term Care Coordinator of the determination.
f. Sends, by facsimile, the completed request form to ABHA
and/or COIHS, AMH and the ECMU Long Term Care
Coordinator.
ECMU Long Term Care
Coordinator
9. If the OHP Member is found appropriate for LTPC, coordinates with
the physician and admission staff the transfer to the Setting
recommended as of the date specified.
AMH 10. If transfer to the LTPC Setting will not occur on the date the OHP
Member is appropriate for LTPC, DHS will assume payment
responsibility for charges related to the Acute Inpatient Hospital
Psychiatric or Other Inpatient Services stay from the effective date of
LTPC until the OHP Member is discharged from such Setting. The
responsibility for payment is subject to the terms and conditions of
the Contract between AMH and each acute Inpatient Hospital.
Effective: January 1, 2011
Schedule 2.1 Page 191 of 221
Determination
Patient's Name:
Prime No.:
□ Approved
□ Denied
Referral Date:
Name of Clinical Decision Maker:
Approval Date:
Date of Determination:
Date Patient Admitted to State Hospital:
Criteria for Long Term Psychiatric Inpatient Care
□ Primary DSM Diagnosis is severe psychiatric disorder
□ Documented need for 24-hour hospital level medical supervision
□ At least one of the following conditions is met:
□ Need for extended (more than 21 days) regulation of medications due to significant complications
arising from severe side effects of medications.
□ Need for continued treatment with electroconvulsive therapy where an extended (more than 21
days) inpatient environment is indicated and the inappropriateness of a short-term or less
restrictive treatment program is documented in the Clinical Record.
□ Continued actual danger to self, others or property that is manifested by at least one of the
following:
□ The OHP Member has continued to make suicide attempts or substantial (life-threatening)
suicidal gestures or has expressed continuous and substantial suicidal planning or
substantial ongoing threats.
□ The OHP Member has continued to show evidence of danger to others as demonstrated by
continued violent acts to person or imminent plans to harm another person.
□ The OHP Member has continued to show evidence of severe inability to care for basic
needs but has potential for significant improvement with treatment.
□ Failure of intensive extended care services evidenced by documentation in the Clinical Record of:
□ An intensification of symptoms and/or behavior management problems beyond the
capacity of the extended care service to manage within its programs; and
□ Multiple attempts to manage symptom intensification or behavior management problems
within the local Acute Inpatient Hospital Psychiatric Care unit.
Effective: January 1, 2011
Schedule 2.1 Page 192 of 221
Outcome of Clinical Review
Upheld
Transfer Date:
Name of Clinical Reviewer:
Reversed
Date of Decision:
Effective: January 1, 2011
Schedule 2.1 Page 193 of 221
Request for Long Term Psychiatric Care Determination for Persons Ages 18 to 64
Request
Contractor:
Referral Date:
OHP Member Name:
DOB:
Prime No (Required):
DSM
Axis I
DSM
Axis II
DSM
Axis III
Admission Date:
Proposed Transfer
Date:
Basis for Request (NOTE: All documents must be attached.)
There is a need for either:
Intensive Psychiatric Rehabilitation or other Tertiary Treatment in an State Hospital or
Extended Care Program, or
Extended and Specialized Medication Adjustment (psychotropic) in a secure or otherwise
highly supervised environment; and
The OHP Member has received all Usual and Customary Treatment including, if Medically
Appropriate, establishment of a medication program and use of a Medication Override
Procedure.
Documentation Supporting Request (NOTE: All documents must be attached.)
Physician's history and physical
List of current medications, dosages and length of time on medication
Reports of other Consultations
Social histories
Current week's progress notes
Analysis of Documentation Supporting Request
Update 7/10
Effective: January 1, 2011
Schedule 2.2 Page 194 of 221
Schedule 2.2 – Procedure for Long Term Psychiatric Care
Determinations for OHP Members 17 and Under
Actor Action
1. If the length of stay in an Acute Care Setting or the OHP Member’s
symptoms in a Psychiatric Residential Treatment Service (PRTS)
might exceed Usual and Customary Treatment, the identified care
coordinator or CCC Chairperson consults with the following
regarding a potential need for LTPC:
CCC Chairperson
a. For OHP Members age 17 and under, the CCC Chairperson
contacts the AMH Representative during normal business
hours (Monday through Friday, 8 a.m. to 5 p.m.).
b. Completes a Request for LTPC Determination for Persons
Age 17 and Under which includes the following
documentation:
(1) Face Sheet (from current medical record)
(2) Physician's history and physical;
(3) List of current medications, dosages, and length of
time on medication;
(4) Reports of other Consultations;
(5) Current psychosocial Assessment;
(6) Two weeks of current progress notes;
(7) Current psychological Assessment; if determined
Medically Appropriate ;
(8) Release of Information
(9) Current psychiatric Assessment;
(10) Psychiatric care admission history;
(11) Psychiatrist note recommending level of care;
(12) Consent for release of information.
(13) CASII and ESCII score; and
(14) Letter of Approval from the county of responsibility.
2. Sends, by facsimile, the request form and supporting documents to
AMH
Effective: January 1, 2011
Schedule 2.2 Page 195 of 221
Actor Action
AMH Representative
3. Does the following:
a. Completes a preliminary review of the clinical documentation
and initial screening to determine whether the CCC LTPC
criterion is met. Such criteria includes the following:
(1) A primary DSM Axis I Diagnosis is from the OHP
Prioritized List of Health Services;
(2) A DSM Axis V, Child Global Assessment Function
(CGAF) rating of 40 or below;
(3) There is documented evidence that the child has not
responded to all Usual and Customary Treatment in an
Acute Inpatient Hospital Psychiatric Care Setting or
PRTS level of care; and
(4) There is documented evidence that the child’s
psychiatric symptoms have intensified beyond the
capacity of the Acute Inpatient Hospital or PRTS level
of care; or
(5) The current CASII and ECSII score indicates a level
of acuity that requires inpatient psychiatric care;
(6) At least two of the following conditions must be met
related to the primary Diagnosis:
• Clinical documentation of actual imminent
danger to self or others that can reasonably be
expected to improve with intensive treatment
and 24-hour medical management under the
direction of a child psychiatrist;
• Multiple placements (within the past year) in an
attempt to manage symptom intensification or
associated behavioral problems within either an
PRTS program,
• Need for intensive psychiatric review or
adjustment of psychotropic medications
evidenced by either rapid deterioration or failure
to improve despite clinical treatment in a less
restrictive level of care; and
• Need for continued treatment beyond the
reasonable duration of an Acute Inpatient
Hospital Psychiatric Care, Subacute Psychiatric
Care or and documented evidence that
Effective: January 1, 2011
Schedule 2.2 Page 196 of 221
Actor Action
appropriate intensity of treatment cannot be
provided in a less restrictive psychiatric
program or community Setting;
At this time the AMH Representative along with a
SCIP or SAIP contracted Provider will visit the
facility and complete a mental status evaluation of the
OHP Member, review clinical documentation and
interview staff.
CCC Chairperson 4. Schedules a CCC LTPC screening in conjunction with the AMH
Representative.
5. Collects and distributes documentation necessary for the CCC LTPC
screening
6. The CCC Chairperson or designee will schedule and facilitate a
meeting with the identified Child & Family team members, AMH
Representative and other representatives for the OHP Member of
family including child welfare, education, juvenile justice, the current
treatment provider and OHP Member or family advocates.
7. Conducts the CCC LTPC screening.
a. Reviews and discusses admission criteria with the committee.
b. Identifies alternative less restrictive treatment options
including STS funding.
c. AMH will make a final decision based on clinical
documentation, CCC Chairperson and their committee’s input
and Assessment of the OHP Member;
d. The CCC Chairperson notes the final determination.
e. If admission criteria are met, does the following:
(1) Establishes an admission date and time; and
(2) Develops a CCC Care Path Plan.
f. If admission criteria are not met, the CCC Chairperson
determines an appropriate plan of care.
g. Decides whether to accept the decision.
h. If the decision is not accepted, requests a clinical review
within three working days of receiving notice of the screening
decision. Sends a written request and documentation
Effective: January 1, 2011
Schedule 2.2 Page 197 of 221
Actor Action
submitted in accordance with Step 3.c. of this Exhibit to
AMH, Child and Adolescent Services Section via facsimile at
(503) 378-8467.
AMH 8. If transfer to LTPC will not occur on the date the OHP Member is
appropriate for LTPC, DHS assumes payment responsibility for
charges related to the Acute Inpatient Hospital Psychiatric stay from
the effective date of LTPC until the OHP Member is discharged from
such Setting.
Effective: January 1, 2011
Schedule 2.2 Page 198 of 221
Request for Long Term Psychiatric Care Determination for Persons Age 17 and Under
REQUEST
Child’s Name:
Referral Date:
Parent/Guardian:
Address:
Phone:
City:
County:
Child’s Medicaid Prime No:
Child’s SS#:
Contractor:
DOB:
Current Program:
Admission Date:
DOCUMENTATION SUPPORTING REQUEST:
I
II
III
IV
V
CLINICAL DOCUMENTS:
□ A copy of the current services coordination plan;
□ Current CASII or ECSII;
□ Physician history and physical;
□ List of current medications, dosages, and length of time on medication;
□ Reports of other consultations;
□ Current psychosocial Assessment;
□ Two weeks of current weekly progress notes;
Current psychological Assessment (if available);
□ Release of information;
□ Current psychiatric Assessment;
□ Psychiatric assessment and recommendation for SCIP and SAIP; and
□ Psychiatrist note recommending level of care.
Effective: January 1, 2011
Schedule 2.2 Page 199 of 221
SUMMARY OF REASONS FOR REQUEST
Effective: January 1, 2011
Schedule 2.2 Page 200 of 221
Long-Term Psychiatric Care Determination for Persons Age 17 and Under
Child’s Name:
Mental Health Organization:
Name of AMH Representative:
Name of CCC Chairperson:
CRITERIA FOR LONG TERM PSYCHIATRIC INPATIENT CARE
□ Primary DSM Axis I Diagnosis is from the Prioritized List of Health Services
□ A DSM Axis V, CGAF rating of 40 or below
□ Current CASII and ECSII score indicates a level of acuity that requires secure inpatient psychiatric
care
At least two of the following:
□ Clinical documentation of actual imminent danger to self or others that can reasonably be
expected to improve with intensive treatment and 24-hour medical management under the
direction of a child psychiatrist;
□ Multiple placements (within the past year) in an attempt to manage symptom intensification
or associated behavioral problems within either an Acute Inpatient Hospital Psychiatric
Care, Subacute Psychiatric Care or PRTS program,
□ Need for intensive psychiatric review or adjustment of psychotropic medications evidenced
by either rapid deterioration or failure to improve despite clinical treatment in a less
restrictive level of care; and
□ Need for continued treatment beyond the reasonable duration of an Acute Inpatient Hospital
Psychiatric Care, Subacute Psychiatric Care and documented evidence that appropriate
intensity of treatment cannot be provided in a less restrictive psychiatric program or
community Setting;
OUTCOME OF CCC CLINICAL SCREENING
□ Documented evidence that multiple efforts in Treatment approach have been made to manage the
OHP Member’s symptoms and/or behavior in a PRTS program AND the OHP Member could
reasonably be expected to benefit over a short period of time from an increased staffing ratio or
psychiatric management allowing them to remain in the PRTS setting.
OR:
□ The OHP Member is demonstrating emotional and/or behavioral difficulty managing the transition
process from SAIP or SCIP to PRTS AND it can be reasonably expected that the OHP Member will
benefit from additional staffing or increased psychiatric management during the brief period
ensuring a more successful transition.
Outcome of CCC Clinical
Screening
Approved
□ SCIP □ SAIP
□ STS
Start of Care Date:
Date of Decision:
Effective: January 1, 2011
Schedule 2.2 Page 201 of 221
Community Coordinating Committee
Care Path Plan
Child’s Name:
DISCHARGE PLAN AND CRITERIA
If LTPC admission criteria are met, include a written plan for discharge to the least restrictive
appropriate Setting with specific discharge criteria linked to resolution of symptoms and behaviors that
justified admission.
SERVICES RECOMMENDED
If LTPC admission criteria are not met, describe services that are recommended.
Signature of AMH Representative Date:________________
Signature of CCC Chairperson Date:
Update 7/10
Effective: January 1, 2011
Schedule 2.3 Page 202 of 221
Schedule 2.3 – Procedure for Long Term Psychiatric Care Determinations
for OHP Members Requiring Geropsychiatric Treatment
Actor Action
ABHA
1. Determines whether the situation of the OHP Member meets both
of the following criteria:
a. There is a need for either Intensive Psychiatric
Rehabilitation or other Tertiary Treatment in a State
Hospital (or for adults Extended Care Program), or
Extended and Specialized Medication Adjustment
(psychotropic) in a secure or otherwise highly supervised
environment; and
b. The OHP Member has received all Usual and Customary
Treatment including, if Medically Appropriate,
establishment of a medication program and use of a
Medication Override Procedure.
2. If the situation of the OHP Member meets both of the criteria
listed in step 1, determines whether the OHP Member is eligible
for OSH-GTS. To be eligible for these services, the DMAP
Member must be:
a. Age 65 or over, or
b. Ages 18 to 64 and have significant nursing care needs
(e.g., must be bathed, dressed, groomed, fed, and toileted
by staff) due to an Axis III disorder of an enduring nature.
3. With the assistance of Acute Inpatient Hospital Psychiatric Care or
Subacute Psychiatric Care or Other Inpatient Services staff, does
the following:
a. Contacts the OSH Geropsychiatric Outreach and
Consultation Service (OCS) at (503) 945-7136, Monday
through Friday, 8:00 a.m. to 5:00 p.m.;
b. Obtains the Request for Long-Term Care Determination
for Persons Requiring Geropsychiatric Treatment (request
form) from the OSH GTS staff;
c. Assess OHP Member’s capacity to provide informed
consent. If OHP Member is determined unable to provide
informed consent, take appropriate action towards Civil
Commitment for OHP Members not already protected by
guardianship.
d. Obtains all supporting documents listed on the request
form.
Effective: January 1, 2011
Schedule 2.3 Page 203 of 221
Actor Action
ABHA (cont.)
4. Sends, by facsimile, the request form and documents to the OSH
Geropsychiatric OCS Screener at (503) 945-2807.
OCS Screener 5. Within three working days of receiving a completed request form,
does the following:
a. Reviews the request form and documentation for
compliance with criteria for LTPC for persons requiring
OSH-GTS.
b. If necessary, visits the Acute Inpatient Hospital Psychiatric
Care or Subacute Psychiatric Care or Other Inpatient
Services facility to interview staff and the OHP Member.
c. Discusses findings, determination, and placement
alternatives with ABHA or Contractor Representative (i.e.,
the person who sent the request form or other person
designated on the request form).
d. Indicates findings, determination, and effective date of
LTPC as specified in Exhibit B, Part II, Section 1,
Subsection c, Paragraph (10) (c) (iii) of this Agreement on
the request form.
6. If the OHP Member is found appropriate for LTPC at OSH-GTS,
works with OSH-GTS, ABHA, and the Acute Inpatient Hospital
Psychiatric Care or Subacute Psychiatric Care or Other Inpatient
Services facility to set the OSH-GTS admission date and to
coordinate such admission.
7. Sends, by facsimile, the completed request form to ABHA and
requester. Also, forwards a copy of the request form to the
Institutional Revenue Section of DHS.
ABHA
8. If the OHP Member is not found appropriate for LTPC at OSH-
GTS, or is found appropriate on a date other than the date
specified in step 5.d., does one of the following:
a. Accepts the decision of the OCS Screener and provides
appropriate Treatment. Works with Acute Inpatient
Hospital Psychiatric Care or Subacute Psychiatric Care or
Other Inpatient Services staff, Senior and Disabled
Services DHS staff, and in some cases, Enhanced Care
Services staff to develop a plan for continued care and
Treatment.
If the decision is not accepted, requests a clinical review within
three working days of receiving notice of the LTPC determination.
Sends a written request and documentation specified in Step 3.d.
of this Exhibit to the AMH via facsimile at (503) 378-8467.
Effective: January 1, 2011
Schedule 2.3 Page 204 of 221
Actor Action
AMH 9. If ABHA requests a clinical review, sends, by facsimile, the
request form and documentation submitted by ABHA in
accordance with Step 3.d. of this Exhibit to the Clinical Reviewer.
Clinical Reviewer 10. Does the following within three working days of receiving the
clinical review packet:
a. Reviews all documentation submitted by BHA in
accordance with Step 3.d. of this Exhibit.
b. Decides whether the OHP Member is appropriate for
LTPC.
c. Determines the effective date of LTPC as specified in
Exhibit B, Part II, Section 1, Subsection c, Paragraph (10)
(c) of this Agreement, if applicable.
d. Updates the request form.
e. Notifies by phone: ABHA and/or COIHS, AMH and the
OCS Screener of the determination.
f. Sends, by facsimile, the completed request form to ABHA
and/or COIHS, AMH and the OCS Screener.
OCS Screener 11. If the OHP Member is found appropriate for LTPC, coordinates
with the physician and admission staff the transfer to the Setting
recommended as of the date specified.
AMH 12. If transfer to the LTPC Setting will not occur on the effective date
of LTPC, DHS assumes payment responsibility for charges related
to the Acute Inpatient Hospital Psychiatric or Other Inpatient
Services stay from the effective date of LTPC until the OHP
Member is discharged from such Setting
Effective: January 1, 2011
Schedule 2.3 Page 205 of 221
Request for Long-Term Psychiatric Care Determination for Persons Requiring Geropsychiatric
Treatment
REQUEST
Contractor:
Referral Date:
OHP Member Name:
DOB:
Referral Agent:
DSM
Axis I
DSM
Axis II
DSM Axis III
Admission
Date:
Prime Number:
BASIS FOR REQUEST (NOTE: All criteria must be met.)
□ OHP Member is 65 or older or OHP Member is 64 or younger AND has significant nursing care
needs (e.g., must be fed, dressed, groomed, bathed, and toileted by staff) AND these needs arise
from an Axis III disorder of an enduring nature (e.g., Alzheimer's, Huntington's, TBI, CVA)
(Note: A person 64 or under whose nursing care needs arise from acute decompensation of an Axis
I disorder or are the result of behavioral noncompliance would not be admitted to GTS and should
be referred to ECMU.)
□ There is a need for either:
□ Intensive Psychiatric Rehabilitation or other Tertiary Treatment in an State Hospital or
Extended Care Program, or
□ Extended and Specialized Medication Adjustment (psychotropic) in a secure or otherwise
highly supervised environment; and
□ The OHP Member has received all Usual and Customary Treatment, including if Medically
Appropriate, establishment of a medication program and use of a Medication Override
Procedure.
DOCUMENTATION SUPPORTING REQUEST
(NOTE: All documents must be attached and must document the basis for request criteria.)
Physician's history and physical Diagnostic Test results and Lab reports
List of current medications, dosages Guardianship or Civil Commitment documents (if
and length of time on medication applicable)
Reports of other Consultations Civil Commitment investigation report (if available)
Social histories ADL Assessment (if available)
Current week’s progress notes Advance Directive (if available)
Effective: January 1, 2011
Schedule 2.3 Page 206 of 221
Please summarize the reason why the patient needs LTPC.
ANALYSIS OF DOCUMENTATION SUPPORTING REQUEST
(Remainder of form to be completed by Gero Outreach staff.)
DETERMINATION
Patient's Name:
Prime No.:
Approved
Date of
Determination:
Name of Clinical Decision Maker:
Denied
Date Patient Admitted to OSH-GTS:
CRITERIA FOR LONG TERM GEROPSYCHIATRIC INPATIENT CARE
□ Person is 65 or older or person is 64 or under and meets nursing care criteria.
□ Person has a psychiatric/neurological disorder causing severe behavioral disturbances with need for
24 hour hospital level medical supervision.
□ At least one of the following conditions is met:
□ Need for extended (more than 21 days) regulation of medications due to significant
complications arising from severe side effects of medications.
□ Need for continued Treatment with electroconvulsive therapy where an extended (more
than 21 days) inpatient environment is indicated and the inappropriateness of a short-term
or less restrictive treatment program is documented in the Clinical Record.
□ Continued actual danger to self, others or property that is manifested by at least one of the
following:
Effective: January 1, 2011
Schedule 2.3 Page 207 of 221
□ The OHP Member has continued to make suicide attempts or substantial life-threatening
behavior or has expressed continuous and substantial suicidal planning or substantial
ongoing threats.
□ The OHP Member has continued to show evidence of danger to others as demonstrated by
continued destructive acts to person or imminent plans to harm another person.
□ For OHP Members 65 and over ONLY: The OHP Member has continued to show evidence
of severe inability to care for basic needs due to significant decompensation of an Axis I
Diagnosis.
□ Failure of intensive Enhanced Care Services evidenced by documentation in the Clinical Record
of:
□ An intensification of symptoms and/or behavior management problems beyond the capacity
of the Enhanced Care Service to manage within its programs; and
□ A minimum of one attempt to manage symptom intensification or behavior management
problems within the local Acute Inpatient Hospital Psychiatric Care unit.
□ Has received all Usual and Customary Treatment including, if Medically Appropriate,
establishment of a medication program and use of a Medication Override Procedure. Has
received medical evaluation and stabilization of acute medical problems.
OUTCOME OF CLINICAL REVIEW
Upheld
Transfer Date:
Name of Clinical Reviewer:
Reversed
Date of Decision:
Update 7/10
Effective: January 1, 2011
Schedule 3 Page 209 of 221
Schedule 3 – Oregon Patient/Resident Care System
The Oregon Patient/Resident Care System (OP/RCS) contains information on all Consumers
served at any of the state psychiatric hospitals, developmental disability training centers and
psychiatric Acute Care facilities.
1. ABHA shall work with hospital or facility providing Acute Inpatient Hospital Psychiatric
Care Services under this Agreement to ensure the establishment of an electronic means
for the hospital or facility to enter OP/RCS data and submit it to DHS.
a. ABHA shall provide COIHS with a list of hospitals to be used in delivering Acute
Inpatient Hospital Psychiatric Care.
b. ABHA shall identify the name, title and phone number of the person within each
hospital with whom AMH will work to establish the computer hook-up to
OP/RCS.
c. ABHA shall identify the names, titles and phone numbers of persons within each
hospital with whom AMH will work to maintain the accuracy, timeliness and
completeness of OP/RCS data submission.
d. ABHA shall work with AMH and/or COIHS and hospital contact person in
designating a physically secure (locked doors and limited access) location (floor
and room number within hospital) of the stand alone computer to be used to enter
OP/RCS data.
e. ABHA shall assure that hospital contact persons comply with confidentiality
requirements contained in 45 CFR Parts 160 and 164, Subparts A and E, to the
extent that they are applicable, and consistent with other state law or federal
regulations governing privacy and confidentiality of mental health information,
sign the request for access/assurance of confidentiality form, and return the form
to AMH.
2. ABHA or its subcontractors shall electronically submit, within 12 hours of admission to
Acute Inpatient Hospital Psychiatric Care, OP/RCS information for Acute Inpatient
Hospital Psychiatric Care Services provided to OHP Members as indicated in the
following table.
Effective: January 1, 2011
Schedule 3 Page 211 of 221
Data Element Admission Discharge
Commitment Type Code 5 X
County of Residence X
County of Responsibility X
County of Discharge X
County of Commitment X
Date of Commitment X
Date of Admission/Discharge X X
Date of Diagnosis X
Date of Birth X
Discharge Reason Code X
Driving Status X
DSM, Axis V Diagnoses X
DSM, Axis IV Diagnoses X
DSM, Axis I Diagnoses X X
DSM, Axis III Diagnoses X X
DSM, Axis II Diagnoses X X
Education Level Achieved X
Ethnic Category Code X
5The Commitment Type Code is changed/updated as applicable.
Effective: January 1, 2011
Schedule 3 Page 212 of 221
Data Element Admission Discharge
Living Arrangement Code X X
Marital Status Code X
Name X
Name, Alias X
Oregon Driver's License Number X
ORS Reference Numbers X
Patient Number X
Referral Source Code X X
Sex X
Social Security Number X
Status of Harm to Property X
Status of Harm to Others X
Status of Suicide X
Status of Harm to Self (Non-Suicide) X
Time of Admission/Discharge X X
Time of Commitment X
Effective: January 1, 2011
Schedule 4 Page 213 of 221
Schedule 4 – Level of Service Intensity Determination Data
ABHA shall use CASII as the statewide tool to assist in the determination for ISA Services for children age six
(6) and older and the ECSII for children birth to five (5).
ABHA shall submit a report to COIHS, within 45 calendar days after the end of each calendar quarter of
the Level of Need Determination screenings completed in that quarter.
□ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
Formatting CASII and ECSII data for submission to AMH:
Data shall be in a comma-delimited format;
Each child shall be represented by a Medicaid ID number and Level of Need Determination Date;
Complete Data Set: A complete data set will be comprised of a minimum of the following elements:
Eight alphanumeric character Medicaid ID number
Child’s date of birth 00/00/0000)
Child’s gender
Date of referral
Referral Source
Date of Determination
ABHA
Scores for CASII Domains I to VI-B (each score must be in the range 1-5) or ECSII Domains I to V.
Composite CASII score or ECSII score.
ISA eligibility Y/N (circle one).
Levels of Care recommended – (Note: Base the recommended level of care on both CASII or ECSII
data and other data indicative of the child’s and family’s needs and/or functioning
Date the child is determined not to be ISA eligible or the last day the child is considered ISA eligible.
Field will be blank if the child continues to be ISA eligible. A blank field will be considered complete.
Instructions for submission and validation of Level of Service Intensity Determination data shall be
provided by AMH as a separate document.
Effective: January 1, 2011
Schedule 5 Page 214 of 221
Schedule 5 - Signature Authorization Form
Contractually required reporting information submitted to AMH must be certified by one of the following:
1. Chief Executive Officer, or similar top executive officer of ABHA, however designated (CEO);
2. Chief Financial Officer, or similar top financial officer of ABHA, however designated (CFO); or
3. An individual who has delegated authority to sign for and reports directly to the CEO or CFO.
Print name and title of CEO or CFO Signature Date
This form shall be due upon effective date of this Agreement.
* Grievance Systems, including Appeal Form (created by ABHA) and Notice of Denial Letter,
* Third Party Resources and Personal Injury Lien Policy and Procedures,
* Utilization Management Policies and Procedures,
* OHP Member Information Materials, including Member Handbook and Annual Notification to OHP
Members Regarding Ability to Participate in Activities of Contractor,
* Policy and Procedure: CASII and ECSII Administration,
* Policy and Procedure for Level of Service Intensity Determination,
* Policy and Procedure for Prevention and Detection of Fraud, Waste and Abuse, and
* Policy and Procedure for Credentialing.
As CEO/CFO/Contractor I authorize the following designated person(s) to certify AMH contractually required
reporting:
Full name and title of the person(s) other than the CEO, CFO or ABHA identified above who has delegated
authority to sign for and who reports directly to the CEO, CFO or ABHA and to certify the data and information
submitted to COIHS:
Print Name and Title Print Name and Title
Signature Date Signature Date
Telephone number Telephone number
(Submit more than one form if more than two persons are delegated to complete the Contractually
Required Reporting Form).
Effective: January 1, 2011
Schedule 5.1 Page 215 of 221
Schedule 5.1 - Attestation of Revision and Submission of Contractually Required Reporting
I, an authorized official of ABHA, certify that the contractually required reporting itemized below have been
reviewed for compliance and content for this Agreement period. In so certifying, ABHA is certifying that the
documents in question below have experienced no further revisions from the last submission to and approval by
AMH.
Signature ________________________________________________
Document Date of Original
review and
approval by
AMH
Current
Contract Year
No Revisions
Made -
Authorized
Signatory
Notes
Grievance Systems
Notice of Action
(Boilerplate)
Appeal Form, created by
ABHA pursuant to CFR
438.400-424
Third Party
Resource/Personal Injury
Lien Policies
&Procedures
Utilization Management
Policies &Procedures
OHP Member
Information Materials and
Plan Member Handbook
Please specify type of
document, e.g. Brochure,
etc.
CASII and ECSII
Administration Policies
&Procedures
Level of Service Intensity
Determination Policies
&Procedures
Prevention/Detection of
Fraud, Waste and Abuse
Policies & Procedures
Credentialing Policies &
Procedures
Effective: January 1, 2011
Schedule 6 Page 216 of 221
Schedule 6 – Key Personnel
ABHA shall submit to COIHS, on the effective date of this Agreement and immediately following
any changes. Information shall include names, telephone numbers, email address and fax number
for the following key personnel: CEO/CFO/ABHA, Director/Manager, Medical Director (if
applicable), Operations Manager (if applicable), Contract Liaison, Quality Assurance/Quality
Improvement Liaison, Children’s Coordinator, Grievance Systems Liaison, Long Term Psychiatric
Care Liaison and Other.
ABHA ABHA Contact Persons
ABHA
Address (Mailing and Location, if different)
Telephone Number
Fax Number
Plan Email address (if applicable)
Fiscal Year:
CEO/CFO/ABHA
Telephone, Fax and
email
Director/Manager
Telephone, Fax and
email
Operations Manager,
(if applicable)
Telephone, Fax and
email
Medical Director,
(if applicable)
Telephone, Fax and
email
Contract Liaison
Telephone, Fax
and email
Quality
Assurance/Quality
Improvement
Liaison
Telephone, Fax
and email
Administrative
Assistant (or
applicable title)
Telephone, Fax
and email
Children’s
Coordinator
Telephone,
Fax and email
Adult
Coordinator
Telephone,
Fax and email
Grievance
Systems
Liaison
Telephone,
Fax and email
Long Term
Psychiatric
Care Liaison
Telephone,
Fax and email
Other,
(if applicable)
Telephone,
Fax and email
Service
Area
(County)
Plan
No.
(M#)
Client
Access
Phone
No.
ITT/TTY/Oregon
Access No.
Effective: January 1, 2011
Schedule 7 Page 217 of 221
Schedule 7 – Integrated Service Array (ISA) Progress Review Report
The ISA Progress Review is to be administered for each child found eligible for ISA services
upon admission and discharge to that level of service. A child shall be reviewed no less than
annually, should the child remain in ISA longer than one (1) year.
Submit data at least once every 90 days. Due 60 calendar days following the end of the
calendar quarter.
Complete Data Set: A complete data set will be comprised of the following elements:
1. Child’s last name, first name.
2. Child’s date of birth (00/00/0000).
3. Date ISA Progress Review was completed using 00/00/0000 format.
4. ISA status of child at time of progress review:
“New”, first review.
“Open”, continuing review.
“Close”, final review.
5. Child’s current residence:
Biological/adoptive family member.
Other than relative/friend (Not foster care).
Long-term foster care placement.
Temporary foster care placement.
Residential treatment center.
Other (include statement describing type of residence).
6. Number of times child changed residence for any reason within the last 90 days.
a. Indicate the number of times that the child has changed residence, for any reason,
in the past 90 calendar days. Do not include planned respite. Do not include
Acute Care hospitalizations. Do not include vacations or recreational stays with
friends or relatives that are unrelated to changes in the child’s condition or the
Family’s circumstances. Do include any planned or unplanned stay with friends
or relatives, if the stay lasted more than seven (7) days and was: (a) precipitated
by a worsening of the child’s condition, a change in the Family’s circumstances,
or increased stress in the child’s environment and; (b) the parent or legal guardian
was made aware of and permitted the stay. (Note: Unplanned stays with others not
permitted by the parent or legal guardian should be regarded as runaways rather
than changes of residence). Each time that a child moves out of and then back to,
his or her primary residence is counted as two (2) moves.
Effective: January 1, 2011
Schedule 7 Page 218 of 221
b. Parent or legal guardian were made aware of and permitted to stay. Each time that
a child moves out of and back to his/her primary residence, count as two (2) stays.
7. Did parent or adult caregiver participate in current and most recent Child and Family
Team (CFT) meeting? (Include those whose primary role with child is that of paid
provider of services, i.e. clinical, educational or case management services.)
8. Caregiver Rating:
a. Social network over the past 30 calendar days:
(1) No family or social network that could help with raising the child.
(2) Some family or friend social network that could help with raising the
child.
(3) Some family or friend social network that actively helps with the raising
of the child.
(4) Significant family and friend social network that actively helps with
raising the child.
(5) NK (Not Known).
b. Child has been producing schoolwork of acceptable quality for his or her ability
level over the past twenty (20) scheduled school days:
(1) Never.
(2) Seldom.
(3) Sometimes.
(4) Frequently.
(5) Very Frequently or Always.
(6) Not applicable (if child has not been in school over past 20 days).
c. Substance abuse over the past 30 days:
0. None.
1. Suspicion of substance abuse.
2. Clear evidence of substance abuse that is interfering with child’s ability to
function in at least one role or setting.
3. Clear evidence of substance dependence and / or child requires
detoxification.
d. Risk of delinquency in consideration of all acts of delinquency (misdemeanors,
felonies and all status offenses except runaways), with or without awareness by
legal authorities:
0. No History.
1. None in past 30 days.
2. Some in past 30 days.
3. Several in past 30 days.
Effective: January 1, 2011
Schedule 7 Page 219 of 221
e. Risk of self-harm (includes reckless or intentional risk taking behavior that may
endanger the child):
0. No history.
1. None in past 30 days.
2. None in past 30 days.
3. Several in past 30 days.
f. History of and risk of danger to others:
0. No history.
1. None in past 30 days.
2. Some in past 30 days.
g. History and risk of running away:
0. No history.
1. None in past 30 days.
2. Some in past 30 days.
3. Several in past 30 days.
9. Behavioral and Emotional Rating Scale, 2nd Edition (Bers2) Parent/Caregiver Rating
Scale, Raw Scores of Subscales.
Formatting the ISA Progress Review Data for Submission to AMH and/or COIHS:
Instructions for submission of the ISA Progress Review Report data shall be provided by AMH
and/or COIHS as a separate document.
Effective: January 1, 2011
Schedule 8 Page 220 of 221
Schedule 8 – OHP Services Not Covered Due to Moral or
Religious Reasons Certification Form
As per 42 CFR 438.102, ABHA is not required to provide coverage or reimburse a counseling or referral
service if Contractor objects to the service on moral or religious grounds. ABHA shall notify COIHS if there
are any services not provided by ABHA due to moral or religious reasons or if there is no limitation on services.
ABHA shall provide this notification on the effective date of this Agreement or implementation of a newly
adopted policy. If ABHA has not changed its policy regarding provision of services since the beginning of the
preceding contract year, it shall so notify COIHS by submission of this Schedule 8.
I certify that ABHA:
Does not limit the Services provided to OHP Member due to moral or religious reasons, or
Does limit the Services provided to OHP Members due to moral or religious reasons. The following
arrangements are made to facilitate receipt of such Services for OHP Members:
Full name and title of the person(s) other than the CEO or CFO who has delegated authority to sign for and who
reports directly to the CEO or CFO and to certify the information submitted to DHS:
Print Name and Title Print Name and Title
Signature Date Signature Date
Telephone number Telephone number
(Submit more than one form if more than two persons are delegated to complete this Certification Form)
Effective: January 1, 2011
Schedule 9 Page 221 of 221
Schedule 9 – Subcontracted Activities
On the effective date of this Agreement, ABHA shall notify COIHS, in writing of activities to be
subcontracted and the entities performing such subcontracted activities. ABHA shall provide a
list which shall include the subcontractor, address, phone number, email address, name of
executive director and activities to be performed. Place an asterisk (*) by those agencies who are
at-risk, subcapitated entities. ABHA shall notify AMH in writing of changes to this list within
30 calendar days of such change.
ABHA subcontracts the following activities. (Please assign an item number to each activity):
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Subcontracted
Activity – Insert all
item numbers that
apply to each
Agency.
Name of
Administrator or
Executive Director
Agency Name Contact
Information-
Address, Phone
Number