Email Address:
  
  Password:
  
  

Exhibit 10.1

MEDICAL SERVICES CONTRACT

 

FLORIDA HEALTHY KIDS CORPORATION

 

AND

 

HEALTHEASE

 

FOR

 

Bay, Citrus, Clay, Duval, Martin, Nassau, and Washington Counties

 

AND

 

WELLCARE HMO/STAYWELL HEALTHPLAN

 

FOR

 

Broward, Miami-Dade, Hernando, Hillsborough, Lee, Orange, Osceola,

Palm Beach, and St. Lucie Counties

 

Effective: October 1, 2009

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

   _______INSURER

 

Page 1 of 63


 

 

FLORIDA HEALTHY KIDS CORPORATION

CONTRACT FOR MEDICAL SERVICES

 

TABLE OF CONTENTS

 

SECTION 1         DEFINITIONS

1-1

Applicant

1-2

Children’s Health Insurance Program

1-3

Children’s Health Insurance Program Re-Authorization Act of 2009

1-4

Children’s Medical Services Network

1-5

Commencement Date

1-6

Comprehensive Medical Care Services

1-7

Contract Year

1-8

Co-Payment

1-9

Effective Date

1-10

Enrollee

1-11

Executive Director

1-12

Federally Qualified Health Center

1-13

Florida Statutes

1-14

Invitation to Negotiate

1-15

Primary Care

1-16

Primary Care Providers

1-17

Program

1-18

Providers

1-19

Rural Health Clinic

1-20

Service Area

1-20

Subcontractor

 

SECTION 2         FHKC

2-1

Coordination of Benefits

 

2-2

Enrollee Identification

2-3

Payments to Insurer

2-4

Insurer Assignment Process

2-5

Monitoring by FHKC

 

SECTION 3         INSURER RESPONSIBILITIES

3-1

General Responsibilities

3-2

Access to Care

 

3-2-1

Enrollment with Primary Care Provider (PCP)

 

3-2-2

Provider Credentialing

 

3-2-3

Geographical Access

 

3-2-4

Appointment Standards

3-3

Failure to Provide Access

3-4

Integrity of Professional Advice

3-5

Benefits

3-6

Claims Payment

3-7

Continuation of Coverage upon Termination of This Contract

3-8

Effective Date of Enrollee Coverage

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 2 of 63


 

 

3-9

Eligibility

3-10

Enrollee Protections from Collections

3-11

Enrollment Procedures

3-12

Extended Coverage

3-13

Fraud and Abuse

 

3-13-1

definition of Fraud and Abuse

 

3-13-2

Fraud Prevention

3-14

Grievances and Complaints

3-15

Indemnification

3-16

Insurance

3-17

Lobbying Disclosure

3-18

Medical Records Requirements

 

3-18-1

Medical Quality Review and Audit

 

3-18-2

Privacy of Medical Records

 

3-18-3

Requests by Enrollees for Medical Records

3-19

Membership and Marketing Materials

 

3-19-1

Use of FHKC and Florida KidCare Marketing Materials

 

3-19-2

Requirements for Member Materials

 3-20

Notification Requirements

 

3-20-1

Immediate Notification Requirements

 

3-20-2

Monthly Notification Requirements

3-21 

Premium Rate Provisions

 

3-21-1

Premium Rate

 

3-21-2

Additional Requirements for Premium Rates

3-22 

Premium Rate Modifications

 

3-22-1

Annual Adjustment Request

 

3-22-2

Annual Premium Rate Adjustment Denials

 

3-22-3

Change in Benefit Schedule

 

3-22-4

Specialty Fee Arrangements

3-23 

Quality Management

 

3-23-1

Quality Improvement Plans

 

3-23-2

Quality Improvement Plan Committee

3-24 

Records Retention and Availability

3-25 

Refusal of Coverage

3-26 

Regulatory Filings

3-27 

Reporting Requirements

3-28 

Subrogation Rights

3-29 

Termination of Participation

3-30 

Use of Subcontractors or Affiliates

3-31 

Reimbursement Requirements

 

3-31-1

Out of Network Providers

 

3-31-2

Reimbursement of Federal Qualified Health Centers and Rural Health Clinics

 

SECTION 4         TERMS AND CONDITIONS

 

4-1

Amendment

4-2

Assignment

4-3

Attachments

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

Page 3 of 63


 

4-4

Attorney Fees

4-5

Bankruptcy

4-6

Change of Controlling Interest

4-7

Confidentiality

4-8

Conflicts of Interest; Non-Solicitation

 

4-8-1

Conflicts of Interest

 

4-8-2

Gift Prohibitions

 

4-8-3

Non-Solicitation

4-9

Effective Dates

4-10

Entire Understanding

4-11

Force Majeure

4-12

Governing Law; Venue

4-13

Independent Contractor

4-14

Name and Address of Payee

4-15

Notice and Contact

4-16

Severability

4-17

Survival

4-18

Termination of Contract

 

A

Termination for Lack of Funding

 

B

Termination for Lack of Payment or Performance

 

C

Termination for Material Breach

 

D

Termination upon Revision of Applicable Law

 

E

Termination by FHKC

 

ATTACHMENTS

 

A

Certification Regarding Debarment

 

B

Certification Regarding Lobbying

 

C

HIPAA Business Associate (BA) Agreement

 

D

Enrollee Benefit Schedule

 

E

List of Required Reports

 

F

Disclosure Form

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 4 of 63


 

 

CONTRACT TO PROVIDE COMPREHENSIVE MEDICAL SERVICES

 

THIS Contract is entered into between the Florida Healthy Kids Corporation (“FHKC”) and WellCare of Florida, Inc.  (“INSURER”) for comprehensive medical care services.

 

SECTION 1         DEFINITIONS

 

As used in this Contract, the term:

 

1-1

“Applicant” means a parent or guardian of a child or a child whose disability of nonage had been removed under chapter 743, F.S. who applies for determination of eligibility for health benefits coverage under ss. 409.810-820 F.S.

 

1-2

“Children’s Health Insurance Program” (CHIP) or “Title XXI” shall mean the program created by the federal Balanced Budget Act of 1997 as Title XXI of the Social Security Act.

 

1-3

“Children’s Health Insurance Program Re-Authorization Act of 2009” or “CHIPRA” means federal legislation (Public Law 111-3-February 4, 2009) effective April 1, 2009 that re-authorized the children’s health insurance program through September 30, 2013.

 

1-4

“Children’s Medical Services Network” (CMSN) means the statewide managed care system which includes health care providers, as defined in Section 391.021(1), F.S., which is financed by Title XXI. CMS network as used under this Contract does not include any additional programs and services by or through CMS network or which are not funded by Title XXI (such services colloquially and collectively known in the regular course of business as “the CMS Safety Net Program”).

 

1-5

“Commencement Date” means that date on which INSURER commenced performance of Comprehensive Medical Care Services to Enrollees.

 

1-6

“Comprehensive Medical Care Services” means those services, medical equipment and supplies to be provided by INSURER in accordance with the standards set by FHKC and further described in Attachment C.

 

1-7

“Contract Year” means October 1 through September 30 th .

 

1-8

“Co-Payment” means the payment required of the Enrollee at the time of obtaining service.

 

1-9

“Effective Date” means the last date on which the last Party to this Contract signed.

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 5 of 63


 

 

1-10 

“Enrollee” means an individual who meets FHKC standards of eligibility and has been enrolled in the Program.

 

1-11

“Executive Director” means the Executive Director of FHKC as appointed by the FHKC Board of Directors.

 

1-12

“Federally Qualified Health Center” means an entity that is receiving a grant under section 330 of the Public Health Service Act, as amended, and Section 1905(1)(2)(B) of the Social Security Act.  FQHCs provide primary health care and related diagnostic services and may provide dental, optometric, podiatry, chiropractic and mental health services.

 

1-13

“Florida Statutes” (F.S.) means the Florida Statutes as amended from time to time by the Florida Legislature during the term of this Contract.

 

1-14

“Invitation to Negotiate” means the procurement document released by the FHKC to competitively secure comprehensive health care services for FHKC Enrollees.

 

1-15

“Primary Care” means comprehensive, coordinated and readily-accessible medical care including: health promotion and maintenance; treatment of illness or injury; early detection of disease; and referral to specialists when appropriate.

 

1-16

“Primary Care Providers” means those physicians licensed in the State of Florida and included in INSURER’s network that are also board certified in Pediatrics or Family Medicine or who have received an exemption from such standards from FHKC.

 

1-17

“Program” means the program administered by FHKC as created by and governed under section 624.91, F.S. and related state and federal laws.

 

1-18

“Providers” means those providers set forth in INSURER’s Response to the Invitation to Negotiate (ITN) and the Enrollee handbook as from time to time may be amended.

 

1-19

“Rural Health Clinic” means a clinic that is located in an area that has a health-care provider shortage.  A RHC provides primary health care and related diagnostic services and may provide optometric, podiatry, chiropractic and mental health services.  A RHC employs, contracts or obtains volunteer services from licensed health care practitioners to provide services.

 

1-20

“Service Area” means the designated geographical areas within which the INSURER is authorized by the Contract to provide services.

 

1-21

“Subcontractor” means any entity or person with whom INSURER has executed a contract to perform services covered under this Contract that may have otherwise been provided for directly by INSURER.

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 6 of 63


 

 

SECTION 2         FHKC

 

2-1           Coordination of Benefits

 

FHKC agrees that INSURER may coordinate health benefits with other insurers as provided for in section 624.91 (5)(c), F.S. and this Contract.  INSURER also agrees to coordinate benefits with any other insurer under contract with FHKC to provide comprehensive dental care benefits to Enrollees, including the provision of prescription coverage by the Enrollee’s health insurer if prescribed by the Enrollee’s dental provider.

 

If INSURER identifies an Enrollee covered through another health benefits program, INSURER shall notify FHKC. FHKC shall decide whether the Enrollee may continue coverage through FHKC in accordance with the eligibility standards adopted by FHKC and in accordance with any applicable state or federal laws.

 

2-2           Enrollee Identification

 

FHKC shall promptly furnish to INSURER enrollment information to sufficiently identify Enrollees in the Comprehensive Medical Care Services Plan authorized by this Contract in accordance with the following:

 

 

A.

Not less than seven (7) working days prior to the start of the coverage month, FHKC shall provide INSURER a listing of Enrollees eligible for coverage that month.

 

 

B.

By the fifth (5 th ) day after the effective date of coverage, FHKC shall also furnish INSURER a supplemental listing of eligible Enrollees for that coverage month. INSURER shall adjust enrollment retroactively to the first (1 st ) day of that month.

 

 

C.

FHKC may request INSURER accept additional Enrollees after the supplemental listing for enrollment retroactive to the first (1 st ) of that coverage month.  Such additions will be limited to those Enrollees who made timely payments but were not included on the previous enrollment reports.  If such additions exceed more than one percent (1%) of that month’s enrollment, INSURER reserves the right to deny FHKC’s request.

 

2-3           Payment to INSURER

 

FHKC will promptly forward the authorized premiums established under Section 3-21 on or before the first (1 st ) day of each month this Contract is in force beginning October 1, 2009.  Premiums are past due if not paid by the fifteenth (15 th ) day of each month.  If premiums are past due, INSURER may terminate coverage under this Contract after giving FHKC notice of the intent to terminate.  Termination of coverage shall be retroactive to the last day for which premium payment has been made.

 

2-4

Insurer Assignment Process

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 7 of 63


 

 

Upon receipt of an application, FHKC shall assign each potential Enrollee to one of the available plans in the Enrollee’s county of residence based upon factors designated by FHKC.  Enrollees will have a ninety (90) day free look period beginning with the Enrollee’s first coverage month with their assigned plan during which time, the applicant or Enrollee may select another available plan without cause.  After this ninety (90) day free look period, Enrollees will be locked until their plan until the Enrollee’s renewal period.

 

FHKC will also notify Enrollees of their right to request disenrollment from their plan and to select another plan outside of the free look period, if such choice is available in their county, as follows:

 

 

A.

For Cause, at the following times:

 

 

1.

The Enrollee has moved out of INSURER’s service area under this Contract;

 

 

2.

The provider does not, because of moral or religions obligations, provide the service that the Enrollee needs;

 

 

3.

The Enrollee needs related services to be performed at the same time; not all related services are available within the INSURER’s network; and the Enrollee’s primary care provider or other provider determines the receiving the services separately would subject the enrollee to unnecessary risk;

 

 

4.

The Enrollee has an active relationship with a health care provider who is not on the INSURER’s network but is in the network of another participating health plan that is open to new enrollees;

 

 

5.

The INSURER no longer participates in the county in which the enrollee resides;

 

 

6.

The Enrollee’s health plan is under a quality improvement plan or corrective action plan relating to quality of care with FHKC; or,

 

 

7.

Other reasons, including but not limited to, poor quality of care, lack of access to services or lack of access to providers experienced in providing care needed by Enrollee.

 

 

B.

At least every twelve (12) months;

 

 

C.

When FHKC grants the Enrollee the right to change health plans without cause, FHKC shall determine the Enrollee’s right to change plans on a case-by-case basis.

 

2-5

Monitoring by FHKC

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 8 of 63


 

 

FHKC will directly or indirectly conduct periodic monitoring of the INSURER’s operations for compliance with the provisions of the Contract and applicable federal and state laws and regulations.

 

SECTION 3            INSURER RESPONSIBILITIES

 

3-1           General responsibilities

 

INSURER shall comply with all provisions of this Contract and its amendments, if any, and shall act in good faith in the performance of the Contract’s provisions.  The INSURER shall develop and maintain written policies and procedures to implement all provisions of this Contract.  INSURER agrees that failure to comply with all provisions of this Contract, applicable federal and state laws and regulations, shall result in the termination of the Contract, in whole or in part, as set forth in this Contract.

 

3-2           Access to Care

 

INSURER shall meet or exceed the appointment and geographic access standards for pediatric medical care existing in the community and as specifically provided in this Contract.

 

INSURER shall maintain a medical network, under staff or contract, sufficient to permit reasonably prompt medical services to all Enrollees in accordance with the terms of this Contract.

 

3-2-1       Enrollment with a Primary Care Provider (PCP)

 

INSURER shall offer each Enrollee a choice of Primary Care Providers that meet the credentialing, access and appointment standards of this Contract.  INSURER may auto-assign the Enrollee to a PCP that meets these requirements upon notification of enrollment; however if auto-assignment is utilized, the Enrollee must be permitted the opportunity to select another PCP within INSURER’s network that meets these requirements.

 

INSURER shall take into consideration, at a minimum, the Enrollee’s last PCP assignment, if known, closest PCP to Enrollee’s home address, zip code location, sibling assignments, and age.

 

INSURER shall provide each Enrollee the following minimum information within five (5) business days of notification of enrollment:

 

 

A.

Notification of Enrollee’s PCP assignment, including contact information for the PCP;

 

 

B.

The Enrollee’s ability to select another PCP from INSURER’s network;

 

 

C.

A provider directory; and,

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 9 of 63


 

 

 

D.

The procedures for changing PCPs.

 

3-2-2       Provider Credentialing

 

A.    Primary Care Providers

 

INSURER’s primary care provider network shall include only board certified pediatricians and family practice physicians or physician extenders working under the direct supervision of a board certified practitioner to serve as primary care physicians in its provider network.

 

All primary care physicians must provide covered immunizations to Enrollees.

 

INSURER may request that an individual Provider be granted an exemption to this requirement by making such a request in writing to FHKC and submitting the proposed Provider’s curriculum vitae and stating a reason why the Provider should be granted an exception. Such requests will be reviewed by FHKC on a case by case basis and a written response will be made to INSURER on the outcome of the request.

 

A medical home, as defined by the American Academy of Pediatrics, with a board certified pediatrician or family practice physician or an exemption provider, must be identified for each Enrollee.

 

B.     Facility Standards

 

Facilities used for Enrollees shall meet applicable accreditation and licensure requirements and meet facility regulations specified by the Agency for Health Care Administration.

 

C.     Behavioral Health Care and Substance Abuse Providers

 

INSURER must maintain a provider network either directly or indirectly that includes qualified provider for child and adolescent substance abuse and behavioral health care services.

 

INSURER and its subcontractors agree to adopt section 394.491, F.S. and Chapter 397, F.S. as guiding principles in the delivery of services and supports to Enrollees with mental health and substance abuse disorders.

 

INSURER shall ensure that all direct behavioral health services provided to children and adolescents under this Contract are delivered by individuals or entities who meet the minimal licensure and credentialing standards set forth in statutes and rules of the Department of Children and Family Services, the Department of Health, and the Division of Medical Quality Assurance of the Agency for Health Care Administration, pertinent to the treatment and prevention of mental health and substance abuse disorders in children and adolescents.

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 10 of 63


 

 

INSURER, at a minimum, shall include within its subcontracted behavioral health care resources a psychiatric hospital licensed under Chapter 395, F. S., a crisis stabilization unit licensed under Chapter 394, F. S., and an addiction receiving facility, licensed under Chapter 397, F. S., which an enrolled child or adolescent may access as needed.

 

INSURER’s provider network shall also include board certified child psychiatrists or practitioners licensed to practice medicine, osteopathic medicine, psychology, clinical social work, mental health counseling, or marriage and family therapy with a minimum of 2 (two) years full-time, post graduate, paid experience providing mental health and/or substance abuse services in a setting that specializes in providing mental health and/or substance abuse services to children and/or adolescents.

 

3-2-3       Geographical Access

 

A.    Primary Care Medical Providers

 

Geographical access to board certified family practice physicians, pediatric physicians, primary care providers or Advanced Registered Nurse Practitioner’s (ARNP), experienced in child health care, of approximately twenty (20) minutes driving time from residence to Provider. This driving time limitation may be reasonably extended in those areas where such limitation with respect to rural residences is unreasonable.  In such instance, INSURER shall provide access for urgent care through contracts with the closest available Providers.

 

B.     Specialty Care Medical Providers

 

Specialty medical services, ancillary services and hospital services are to be available within sixty (60) minutes driving time from Enrollee’s residence to Provider. The driving time limitation may be reasonably extended or waived in those areas where such limitation with respect to rural residences is unreasonable.

 

                3-2-4       Appointment Standards

 

A.    Definitions

 

For the purposes of this Section, the following definitions shall apply:

 

 

1.

“Emergency care” means the level of care required for the treatment of an injury or acute illness that, if not treated immediately, could reasonably result in serious or permanent damage to the Enrollee’s health.

 

 

2.

“Urgently needed care” or “Urgent Care” means the level of care that is required within a twenty-four (24) hour period to prevent a condition from requiring emergency care.

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 11 of 63


 

 

 

3.

“Routine care” means the level of care can be delayed without anticipated deterioration in the Enrollee’s condition for a period of seven (7) calendar days.

 

 

4.

“Routine physical examinations” means the Enrollee’s annual physical examination by the Enrollee’s primary care provider in accordance with the schedule established by the American Academy of Pediatrics.

 

B.     Appointment Access

 

INSURER shall provide timely treatment for Enrollees in accordance with the following standards:

 

 

1.

Emergency care shall be provided immediately.

 

 

2.

Urgently needed care shall be provided within twenty-four (24) hours.

 

 

3.

Routine care of Enrollees who do not require emergency or urgent care shall be provided within seven (7) calendar days of the Enrollee’s request for services.

 

 

4.

Routine physical examinations shall be provided within four (4) weeks of the Enrollee’s request.

 

 

5.

Follow-up care shall be provided as medically appropriate.

 

By utilization of the foregoing standards, FHKC does not intend to create standards of care or access to care different than those deemed acceptable within INSURER’s service area. Rather, FHKC intends that INSURER and its Providers timely and appropriately respond to Enrollee needs, as they are presented, in accordance with standards of care existing within the service area.  In applying these standards, INSURER and Provider shall give due regard to the level of discomfort and anxiety of the Enrollees and their families.

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 12 of 63


 

 

3-3           Failure to Provide Access

 

In the event FHKC determines that INSURER or its Providers, has failed to meet the access standards established in this Contract, FHKC shall notify INSURER of its non-compliance. Such notice may be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow INSURER to investigate and respond within five (5) business days for non-emergency care. Response to emergency or urgent non-compliance issues must be immediate upon receipt of notice.

 

If any such failure to provide access constitutes a material breach of this Contract, as determined by FHKC in its sole discretion, such material breach shall entitle FHKC to unilaterally terminate this Contract.  Termination for material breach shall proceed pursuant to Section 4-18(C).

 

Upon FHKC identifying a material breach by INSURER, to address the ongoing health care needs of Enrollees, FHKC may direct Enrollees to seek such services outside of INSURER’s Provider network. Should FHKC direct such action, INSURER shall be financially responsible for all such services.

 

3-4           Integrity of Professional Advice to Enrollees

 

INSURER must comply with section 457.985, Code of Federal Regulation (CFR) which prohibits INSURER from interfering with the advice of health care professionals to Enrollees and requires that professionals engaged in the performance of INSURER’s duties under this Contract give information about treatments to Enrollees and their families as provided by law.

 

Likewise, INSURER agrees to comply with section 457.985, CFR and any other applicable federal or state laws and regulations related to physician incentive plans including any disclosure requirements related to such incentive plans.

 

3-5           Benefits

 

INSURER agrees to make its provider network available to Enrollees in those counties designated under Section 3-21 and to provide the Comprehensive Medical Care Services in this Contract.

 

3-6           Claims Payment

 

INSURER will pay any claims from its offices located at 5404 Cypress Center Drive, Suite 300 Tampa, FL 33609 or any other designated claims office located in its service area.  INSURER will pay clean claims filed within thirty (30) business days or request additional information of the claimant necessary to process the claim.

 

3-7           Continuation of Coverage upon Termination of this Contract

 

INSURER agrees that, upon termination of this Contract for any reason, unless instructed otherwise by FHKC, it will continue to provide inpatient services to Enrollees who are then inpatients until such time as Enrollees have been appropriately discharged.  However, INSURER shall not be required to provide such extended benefits beyond twelve (12) calendar months from the date the Contract is terminated.

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 13 of 63


 

 

If INSURER terminates this Contract at its sole option and through no fault of FHKC, and if on the date of termination an Enrollee is totally disabled and such disability commenced while coverage was in effect, that Enrollee shall continue to receive all benefits otherwise available under this Contract for the condition under treatment which caused such total disability until the earlier of:

 

A.           Expiration of the contract benefit period for such benefits;

 

 

B.

Determination by the Medical Director of INSURER that treatment is no longer medically necessary;

 

 

C.

Expiration of twelve (12) months from the date of termination of coverage; or,

 

 

D.

Election by a succeeding carrier to provide replacement coverage without limitation as to the disabling condition.

 

However, these benefits will be provided only so long as the Enrollee is continuously totally disabled and only for the illness or injury which caused the total disability.

 

For purposes of this section, an Enrollee who is “totally disabled” shall mean an Enrollee who is physically unable to work, as determined by the Medical Director of INSURER, due to an illness or injury at any gainful job for which the Enrollee is suited by education, training, experience or ability.  Pregnancy, childbirth or hospitalization in and of themselves does not constitute “total disability”. In the case of maternity coverage, when an Enrollee is eligible for such coverage and when not covered by a succeeding carrier, a reasonable period of extension of benefits shall be granted.  The extension of benefits shall be limited to the maternity services and newborn care benefits provided under this Contract and shall not be based on total disability.

 

3-8           Effective Date of Enrollee Coverage

 

Coverage for every Enrollee shall become effective at 12:01 a.m. EST/EDT, on the first day of the Enrollee’s first coverage month, as determined by FHKC.

 

3-9           Eligibility

 

INSURER shall accept those Enrollees which FHKC has determined meet the Program’s eligibility requirements.

 

A.           Program Eligibility

 

The following eligibility criteria for participation in the Program must be met:

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 14 of 63


 

 

 

1.

Enrollees must be children who are age five (5) years through eighteen (18) years. Age eligibility shall end on the last day of the month in which the Enrollee

attains age nineteen (19).  Age eligibility is based on the Enrollee’s age as of the first day of the coverage month.

 

 

2.

Enrollees must meet the eligibility criteria established under section 624.91, F.S. and as implemented by the FHKC Board of Directors.

 

 

3.

Eligible Enrollees may enroll during time periods established by FHKC Board of Directors in accordance with section 624.91, F.S.

 

 

4.

Determination of eligibility for the Program is made solely by FHKC.

 

B.            Requests for Eligibility Review

 

If INSURER has reasonable cause to believe that an Enrollee is not eligible for the Program because that Enrollee should in fact be placed in a different state or federal program for such services which eligibility would render that Enrollee ineligible for the Program, INSURER may request in writing that FHKC review the eligibility of that Enrollee. FHKC shall ensure that all records and findings maintained by FHKC concerning a particular eligibility determination will be made available to INSURER with reasonable promptness to the extent permitted under sections 624.91 and 409.821, F.S. regarding confidentiality of information held by FHKC and the Florida KidCare program.

 

C.            Eligibility Dispute Process

 

If after review under this section, INSURER and FHKC dispute whether or not an Enrollee is eligible for the Program, upon payment of a one hundred dollar ($100.00) fee to FHKC from INSURER, FHKC will seek an independent determination of eligibility from the entity administering the comparable federal or state insurance program for which INSURER alleges the Enrollee is eligible.  Both INSURER and FHKC agree to be bound by the response of the entity receiving the request under this provision.  INSURER and FHKC agree that the rights and remedies provided under this section shall be exclusive as to eligibility disputes.

 

If an Enrollee is determined not to be eligible for the Program and INSURER included that Enrollee in an actuarial memorandum to support a premium or rate modification request under this Contract, then INSURER shall submit to FHKC a revised supporting actuarial memorandum which excludes that Enrollee.

 

3-10         Enrollee Protections from Collection

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 15 of 63


 

 

Neither INSURER nor any representative of INSURER shall collect or attempt to collect from an Enrollee any money for services covered by the Program or any monies owed by FHKC to INSURER.

 

3-11         Enrollment Procedures

 

Within five (5) business days of receipt of an enrollment file specified under Section 2-2, INSURER shall provide each Enrollee with an enrollment package. The enrollment package shall include, at a minimum, the following items:

 

 

A.

A membership card displaying the Enrollee’s name, identification number and effective date of coverage as well as any other information required by state or federal law.

 

 

B.

An Enrollee handbook that complies with any federal or state requirements and has been approved by FHKC.  The handbook shall include a description of how to access services, a listing of any Co-Payment requirements, INSURER’s grievance process and the covered benefits. Co-Payment requirements shall specifically explain that in the event the Enrollee fails to pay the required Co-Payment, INSURER may decline to provide non-emergency or non-urgently needed care unless the Enrollee meets the conditions of waiver of Co-Payments described in Attachment D.

 

 

C.

A current listing of all participating primary care physicians, specialists and other medical providers that includes the address, office hours and any age limitations for each Provider.

 

Any cancellation of Enrollees from coverage shall be processed timely by INSURER upon receipt of the monthly enrollment files. INSURER will provide written notice of the effective date of cancellation, by regular mail, to each affected Enrollee within five (5) business days of receipt of such information.

 

INSURER must also comply with the guidance issued by the Office of Civil Rights of the United States Department of Health and Human Services (“Policy Guidance on Title VI Prohibition against National Origin Discrimination as it Effects Persons with Limited English Proficiency) regarding the availability of information and assistance for persons with limited English proficiency.

 

3-12         Extended Coverage

 

Except for terminations resulting from fraud, INSURER agrees to offer individual coverage to all terminated Enrollees without regard to health condition status.

 

3-12

Fraud and Abuse

 

                3-13-1

Definition of Fraud and Abuse

 

Florida Healthy Kids Corporation 

 

         /s/ RR   FHKC

Effective Date -October 1, 2009

 

    /s/ HS  INSURER

 

Page 16 of 63


 

 

The following acts by a FHKC Applicant, Enrollee or other person are considered Fraud:

 

 

A.

Knowingly failing by any false statement, misrepresentation, impersonation, or other fraudulent means, to disclose any material fact necessarily used in making the determination as to such person’s qualification to receive Comprehensive Medical Care Services coverage under the Program;

 

 

B.

Knowingly failing to disclose a change in circumstances in order to obtain or continue to receive Comprehensive Medical Care Services under the Program to which he or she is not entitled or in an amount larger than that to which he or she is entitled.

 

 

C.

Using or attempting to use, transfer, acquire, traffic, alter, forge, or possess a FHKC identification card to which he or she is not entitled.

 

 

D.

Committing any act subject to prosecution under Section 409.814, F.S.

 

 

E.

Aiding or abetting another person in the commission of any act under this definition.

 

3-13-2     Fraud Prevention

 

INSURER shall have in place appropriate preventative and detection measures which ensure against fraud and abuse as defined in this Contract that complies with all state and federal laws and regulatory requireme


This is only a partial view of this document. We have millions of legal documents and clauses drafted by top law firms. learn more search for free browse for free learn more