Appendix AA Denver Health Medicaid Choice Contract

120 Pages·2017·0.72 MB·English

SOLICITATION #:
2017000265

Appendix AA
Denver Health Medicaid Choice Contract
APPENDIX AA

Denver Health Medicaid Choice Contract
Contract Number 2016MEDMCO001A2
CONTRACT AMENDMENT NO. 02
Original Contract Number 2016MEDMCO001
1. PARTIES
This Amendment to the above-referenced Original Contract (hereinafter called the “Contract”) is entered
into by and between Denver Health and Hospital Authority dba Denver Health Medicaid Choice, a body
corporate and political subdivision of the State of Colorado, 777 Bannock Street, Denver, CO, 80204,
(hereinafter called “Contractor”), and the STATE OF COLORADO, acting by and through the Department
of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203 (hereinafter called
“Department” or “State.”)
2. EFFECTIVE DATE AND ENFORCEABILITY
This Amendment shall not be effective or enforceable until it is approved and signed by the Colorado State
Controller or designee (hereinafter called the “Effective Date.”) The Department shall not be liable to pay
or reimburse Contractor for any performance hereunder, including, but not limited to, costs or expenses
incurred, or be bound by any provision hereof prior to the Effective Date.
3. FACTUAL RECITALS
The Parties entered into the Contract to have Denver Health and Hospital Authority perform as a Managed
Care Entity for the Department. The purpose of this Amendment is to extend the contract, update the
Statement of Work, update Exhibit D, and update Exhibit M.
4. CONSIDERATION
The Parties acknowledge that the mutual promises and covenants contained herein and other good and
valuable consideration are sufficient and adequate to support this Amendment.
5. LIMITS OF EFFECT
This Amendment is incorporated by reference into the Contract, and the Contract and all prior amendments
thereto, if any, remain in full force and effect except as specifically modified herein.
6. MODIFICATIONS
The Contract and all prior amendments thereto, if any, are modified as follows:
A. Section 4, Definitions, Subsection C, Exhibits and other Attachments, is hereby deleted in its
entirety and replaced with the following:
C. Exhibits and other Attachments. The following documents are attached hereto and
incorporated by reference herein:

HIPAA Business Associate Addendum
Exhibit A, Statement of Work
Exhibit B, Rates
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Exhibit C, Sample Option Letter
Exhibit D, Covered Services
Exhibit E, Disproportionate Share and Graduate Medicaid Education Hospital Reporting by
Calendar Year Quarter
Exhibit F, Member Handbook Requirements
Exhibit G, Requirements for Physician Incentive Plans
Exhibit H, Contractor Disclosure Template
Exhibit I, Covered Behavioral Health Procedure Codes
Exhibit J, Medicaid Managed Care Grievance and Appeal Processes
Exhibit K, Serious Reportable Events or Never Events
Exhibit L, Enrollment Retention Rate Disenrollment Codes
Exhibit M, Procedure Codes for Enhanced Payments
Exhibit N, Colorado Family Planning Methodology

B. Section 5, Term, is hereby deleted in its entirety and replaced with the following:
5. TERM
A. Initial Term
The Parties’ respective performances under this Contract shall commence on July 1,
2016. This Contract shall expire on June 30, 2017, unless sooner terminated or further
extended as specified elsewhere herein.
B. Two Month Extension
The State, at its sole discretion, upon written notice to Contractor as provided in §16,
may unilaterally extend the term of this Contract for a period not to exceed two months
if the Parties desire to continue the services and a replacement Contract has not been
fully executed by the expiration of any initial term or renewal term. The provisions of
this Contract in effect when such notice is given, including, but not limited to, prices,
rates and delivery requirements, shall remain in effect during the two month extension.
The two (2) month extension shall immediately terminate when and if a replacement
contract is approved and signed by the Colorado State Controller or an authorized
designee, or at the end of two (2) months, whichever is earlier.
C. Option to Extend
The State may require continued performance for a period of one (1) year or less at the
same rates and same terms specified in the Contract. If the State exercises this option, it
shall provide written notice to Contractor at least thirty (30) days prior to the end of the
current Contract term in form substantially equivalent to Exhibit C. If exercised, the
provisions of the Option Letter shall become part of and be incorporated into this
Contract.
C. Section 12, Representations and Warranties, Subsection D, State Plan, is hereby added as
follows:
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D. State Plan
The Department warrants that the services outlined within this Contract are consistent with
the services authorized in the State Plan.
D. Section 16, Notices and Representatives, contacts For the State and For the Contractor, are
hereby deleted in their entirety and replaced with the following:
For the State: Chris Tzortzis
Department of Health Care Policy and Financing
1570 Grant Street
Denver, Colorado 80203
[email protected]

For the Contractor: Craig Gurule
Denver Health and Hospital Authority
777 Bannock Street
Mailcode 6000
Denver, CO 80204
[email protected]

E. Section 19, General Provisions, Subsection H, Order of Precedence, is hereby deleted in its
entirety and replaced with the following:
H. Order of Precedence
The provisions of this Contract shall govern the relationship of the State and Contractor. In
the event of conflicts or inconsistencies between this Contract and its exhibits and
attachments, including, but not limited to, those provided by Contractor, such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of
priority:
i. Colorado Special Provisions
ii. HIPAA Business Associate Addendum
iii. The provisions of the main body of this Contract
iv. Exhibit A, Statement of Work
v. Exhibit B, Rates
vi. Exhibit C, Sample Option Letter
vii. Exhibit D, Covered Services
viii. Exhibit E, Disproportionate Share and Graduate Medicaid Education Hospital
Reporting by Calendar Year Quarter
ix. Exhibit F, Member Handbook Requirements
x. Exhibit G, Requirements for Physician Incentive Plans
xi. Exhibit H, Contractor Disclosure Template
xii. Exhibit I, Covered Behavioral Health Procedure Codes
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xiii. Exhibit J, Medicaid Managed Care Grievance and Appeal Processes
xiv. Exhibit K, Serious Reportable Events or Never Events
xv. Exhibit L, Enrollment Retention Rate Disenrollment Codes
xvi. Exhibit M, Procedure Codes for Enhanced Payments
xvii. Exhibit N, Colorado Family Planning Methodology

F. Exhibit A, Statement of Work, is hereby deleted in its entirety and replaced with Exhibit A1,
Statement of Work, attached hereto and incorporated by reference in to the Contract. All
references within the Contract to Exhibit A shall be deemed to reference Exhibit A1.
G. Exhibit B, Rates, is hereby deleted in its entirety and replaced with Exhibit B1, Rates, attached
hereto and incorporated by reference in to the Contract. All references within the Contract to
Exhibit B shall be deemed to reference Exhibit B1.
H. Exhibit D, Covered Services, is hereby deleted in its entirety and replaced with Exhibit D1,
Covered Services, attached hereto and incorporated by reference in to the Contract. All
references within the Contract to Exhibit D shall be deemed to reference Exhibit D1.
I. Exhibit F, Member Handbook Requirements, is hereby deleted in its entirety and replaced with
Exhibit F1, Member Handbook Requirements, attached hereto and incorporated by reference in
to the Contract. All references within the Contract to Exhibit F shall be deemed to reference
Exhibit F1.
J. Exhibit J, Medicaid Managed Care Grievance and Appeal Processes, is hereby deleted in its
entirety and replaced with Exhibit J1, Medicaid Managed Care Grievance and Appeal
Processes, attached hereto and incorporated by reference in to the Contract. All references
within the Contract to Exhibit J shall be deemed to reference Exhibit J1.
K. Exhibit M, Covered 1202 Procedure Codes, is hereby deleted in its entirety and replaced with
Exhibit M1, Procedure Codes for Enhanced Payments, attached hereto and incorporated by
reference in to the Contract. All references within the Contract to Exhibit J shall be deemed to
reference Exhibit M1.
L. Exhibit N, Colorado Family Planning Methodology, attached hereto and referenced herein is
hereby added to the Contract.
7. START DATE
This Amendment shall take effect on July 1, 2016.
8. ORDER OF PRECEDENCE
Except for the Special Provisions and the HIPAA Business Associates Addendum, in the event of any
conflict, inconsistency, variance, or contradiction between the provisions of this Amendment and any of the
provisions of the Contract, the provisions of this Amendment shall in all respects supersede, govern, and
control. The most recent version of the Special Provisions incorporated into the Contract or any amendment
shall always control other provisions in the Contract or any amendments.
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9. AVAILABLE FUNDS
Financial obligations of the state payable after the current fiscal year are contingent upon funds for that
purpose being appropriated, budgeted, or otherwise made available to the Department by the federal
government, state government and/or grantor.
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Contract Number Error! Reference source not found.A2 Error! Reference source not found.
THE PARTIES HERETO HAVE EXECUTED THIS AMENDMENT
Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor’s behalf
and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE OF COLORADO:
Denver Health and Hospital
AuthorityError! Reference source not
found. John W. Hickenlooper, Governor

By: By:
Signature of Authorized Officer Susan E. Birch, MBA, BSN, RN
Executive Director
Department of Health Care Policy and
Financing
Date:
Date:

LEGAL REVIEW:
Printed Name of Authorized Officer Cynthia H. Coffman, Attorney General

By:

Printed Title of Authorized Officer Date:

ALL CONTRACTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until
signed and dated below by the State Controller or delegate. Contractor is not authorized to begin
performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not
obligated to pay Contractor for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER:
Robert Jaros, CPA, MBA, JD
By:
Department of Health Care Policy and Financing
Date:

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EXHIBIT A, STATEMENT OF WORK

SECTION 1.0 TERMINOLOGY
1.1. ADDITIONAL ACRONYMS, ABBREVIATIONS AND DEFINITIONS
1.1.1. Acronyms and abbreviations are defined at their first occurrence in this Statement of Work. The
following list of acronyms, abbreviations and definitions is provided to assist the reader in
understanding acronyms, abbreviations and terminology used throughout this document.
1.1.1.1. “Adjusted Medical Expenditures” means encounter data submitted by the Contractor that are
priced for internal providers to reflect the State’s fee schedule and using the paid amount on
the encounter data for external providers, and exclude any and all administrative costs and
amounts equal to the Co-Payments in place for Medicaid FFS at the time, regardless of
whether the Contractor collected on the Co-payments from Enrollees or not. Actual Medical
Expenditures must be reduced by any recoveries from other payers including those pursuant
to coordination of benefits, third party liability, reinsurance, rebates, or adjustments in claims
paid or from providers, including adjustments to claims paid.
1.1.1.2. “Administrative Services Fee” or “ASF” means the per member per month payment to
Contractor to provide the range of administrative services contained in this Contract, as
described in section 5.2 of this Statement of Work. The Administrative Services Fee shall
not include the direct cost of medical care.
1.1.1.3. "Advance Directive" means a written instrument, such as a living will or durable power of
attorney for health care, recognized under Section 15-14-505(2), C.R.S., and defined in 42
C.F.R. 489.100, relating to the provision of health care when the individual is incapacitated.
1.1.1.1. “Business Day” means any day in which the Department is open and conducting business,
but shall not include weekend days or any day on which the Department observes one of the
following holidays :
1.1.1.1.1. New Year's Day.
1.1.1.1.2. Martin Luther King, Jr. Day.
1.1.1.1.3. Washington-Lincoln Day (also referred to as President’s Day).
1.1.1.1.4. Memorial Day.
1.1.1.1.5. Independence Day.
1.1.1.1.6. Labor Day.
1.1.1.1.7. Columbus Day.
1.1.1.1.8. Veterans’ Day.
1.1.1.1.9. Thanksgiving Day.
1.1.1.1.10. Christmas Day.
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1.1.1.2. “Care Coordination” means the process of identifying, screening and assessing Members’
needs, identification of and Referral to appropriate services, and coordinating and monitoring
an individualized treatment plan. This treatment plan shall also include a strategy to ensure
that all Members and/or authorized family members or guardians are involved in treatment
planning and consent to the medical treatment.
1.1.1.3. “Clean claim” means a claim for payment with all required fields completed with correct and
complete information, including all required documents.
1.1.1.4. “Client” means a recipient of the Medicaid program.
1.1.1.5. "Communication Disability" means an expressive or receptive impairment that creates a
barrier to communication between a Member and a person not familiar with that Member.
1.1.1.6. “Contractor’s Plan” means the Contractor’s network or those Covered Services provided by
the Contractor to eligible Clients in accordance with the terms and conditions of this
Agreement.
1.1.1.7. "Covered Drugs" means those drugs currently covered by the Medicaid program and includes
those products that require prior authorization by the Colorado Medicaid program. Covered
Drugs shall be dispensed by a Participating Provider except for Emergency Services and
shall be prescribed by Participating Providers or requested by an authorized prescriber as a
result of authorized Referral, Emergency Services, dental care, or obtained under the
Medicaid Mental Health Capitation Program.
1.1.1.8. "Covered Services" means those services described in Exhibit D, attached hereto and made
part of this contract, which the Contractor is required to provide or arrange to be provided to
a Member in return for the Monthly Payment Rate.
1.1.1.9. "Desk Audit" means the review of materials submitted upon request to the Department or its
agents for quality assurance activities.
1.1.1.10. "Designated Client Representative" means the person as defined at 10 C.C.R. 2505-10,
Section 8.209.2.
1.1.1.11. “Disability" or "Disabilities" means, with respect to a Member, a physical or mental
impairment that substantially limits one or more of the major life activities of such Member
in accordance with the Americans with Disabilities Act of 1990, 42 U.S.C. Section 12101,
et seq.
1.1.1.12. "Disenrollment" or “Disenroll” means the act of discontinuing a Member’s Enrollment in the
Contractor’s Plan.
1.1.1.13. “EI” means the Early Intervention program that provides developmental supports and
services to children birth through two years of age who have special developmental needs. It
can help improve a child’s ability to develop and learn. It can also help you and your family
learn ways to support and promote your child’s development, within your family activities
and community life. The EI Colorado program provides EI services, such as occupational,
speech or physical therapy, to help infants and toddlers grow and develop, and to help their
family in this process. It is a voluntary program and does not discriminate based on race,
culture, religion, income level, or disability.
1.1.1.14. "Emergency Medical Condition" means a medical condition as defined at 42 C.F.R. Section
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