HEALTH PLAN OF SAN MATEO
MEDI-CAL
NURSING FACILITY AGREEMENT
Table of Contents
RECITALS 1
DEFINITIONS 1
NURSING FACILITY PERFORMANCE PROVISIONS 7
PLAN PERFORMANCE PROVISIONS 10
REIMBURSEMENT FOR SERVICES 11
PAYMENT PROCEDURES 11
INSURANCE 12
RECORDS, AUDITS, AND REPORTS 14
PATIENT RIGHTS 17
TERM, TERMINATION, AND EFFECT OF TERMINATION 19
INTERRUPTIONS 21
GENERAL PROVISIONS 22
GRIEVANCES AND DISPUTE RESOLUTIONS 23
MISCELLANEOUS 24
NOTICES 26
LIST OF EXHIBITS 26
NURSING FACILITY AGREEMENT
This Agreement is made this First day of _________, 200_, by and between the San Mateo Health Commission, d.b.a. Health Plan of San Mateo, hereinafter referred to as “PLAN”, and ________________,____________, hereinafter referred to as "NURSING FACILITY."
WHEREAS, the PLAN is an independent public agency authorized to negotiate and to enter into nursing facility agreements with institutional health care providers for the purpose of arranging for the provision of "Medi-Cal Benefits", as that term is defined and more particularly set forth in this Agreement, (hereinafter referred to as "Benefits" or "Covered Services"), to "Medi-Cal Members", as that term is defined and more particularly set forth in this Agreement and in the PLAN's Medi-Cal Services Contract with the State of California; and
WHEREAS, the NURSING FACILITY, is licensed as a Skilled Nursing Facility or Intermediate Care Facility by the Department of Health Care Services (DHCS) or is a distinct part or unit of a hospital, and has been certified by DHCS for participation as a Skilled Nursing Facility in the Medi-Cal program, and is equipped, staffed, and prepared to provide Medi-Cal Benefits to Medi-Cal Members; and
WHEREAS, the parties hereto desire to enter into this Agreement to provide a statement of their respective rights and responsibilities in connection with the provision of Medi-Cal Benefits to San Mateo County Medi-Cal Members by the NURSING FACILITY during the term hereof;
NOW THEREFORE, in consideration of the mutual promises and covenants hereinafter contained the parties agree as follows:
ARTICLE I
General Meaning of Words and Terms - The words and terms used in this Agreement, and any and all attachments, are intended to have their usual meanings unless a particular or more limited meaning is associated with their usage in Sections 14000 et seq. of the Welfare and Institutions Code or the Knox-Keene Health Care Services Plan Act of 1975, as amended (the “Act”) Sections 1340 et seq. of the Health and Safety Code, and/or Title 22 and Title 28 of the California Code of Regulations pertaining to the rendition of health care, or unless specifically defined in this Article I or otherwise in this Agreement.
A. "Claim" shall mean a claim for compensation for services to PLAN Members filed by the NURSING FACILITY in accordance with Medi-Cal policy and procedures as defined in Title 22, State Fiscal Intermediary Provider Manual and bulletins, and as specifically modified by the PLAN issued Provider Manual and bulletins.
B “Contracting Nursing Facility” shall mean a Nursing Facility which has executed an Agreement with the PLAN to provide services to PLAN Members as specified in the Hospital Services Agreement.
C. "Contracting Physician" shall mean a person who holds a degree of Doctor of Medicine or Osteopathy, who is licensed to practice medicine in the State of California, and who has contracted with the PLAN to provide medical services to Medi-Cal Beneficiaries.
D. "Contracting Provider" shall mean a health professional or institution licensed and certified to provide Covered Services to Medi-Cal Members and who has executed an Agreement with the PLAN.
E. "Contracting Primary Care Physician" or "PCP" shall mean a physician or physicians who have executed an Agreement with PLAN to provide the services of a Primary Care Physician as specified in PLAN's Primary Care Physician Contract.
F. “Downstream Entity” – means any party that enters into an acceptable written arrangement below the level of the arrangement between a Plan and a First Tier Entity. These written arrangements continue down to the level of the ultimate provider of health and/or administrative services.
G “Emergency Medical Condition” shall mean a medical condition which is manifested by acute symptoms of sufficient severity, including severe pain, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
a) placing the health of an individual (or, in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
b) serious impairment of bodily functions, or
c) serious dysfunction of any bodily organ or part.
H “Emergency Services” shall mean those services furnished by a qualified provider which are needed to evaluate or stabilize an Emergency Medical Condition.. Emergency services and care to treat an Emergency Medical Condition include psychiatric screening, examination, evaluation, and treatment by a physician or other personnel to the extent permitted by applicable law and within the scope of their licensure and privileges.
I “Evidence of Coverage” shall mean the document issued by the PLAN to Members that describes Covered Services and Non-Covered Services in the PLAN.
J “Excluded Services” shall mean those health care services which are excluded as non-covered services in PLAN’s Evidence of Coverage and for which the Member is financially responsible. These services may also be called “Non-Covered Services”.
K “Facility Services” shall mean services that include, but are not limited to, the following services when ordered by a Member’s responsible physician or other qualified health practitioner and rendered to Members in accordance with the W&I Codes, applicable sections of 22 CCR for Skilled Nursing Facilities and intermediate care facilities, subject to any exclusions, limitation, exceptions, and conditions as may be set forth in the Agreement:
(i) room and board; (ii) nursing and related care services; (iii) commonly used items of equipment, supplies and services used for the medical and nursing benefit of Members in applicable provisions of the State Medi-Cal program referenced in 22 CCR; and (iv) administrative services required in providing inpatient services.
L. “Health Plan of San Mateo” (HPSM) shall mean the health plan governed by the San Mateo Health Commission.
M. “Identification Card” shall mean that card which is issued by the PLAN to each covered Member and that bears the name and symbol of the PLAN and contains: Member’s name, Member’s identification number, Member’s Primary Care Physician and other identifying data. The Identification Card is not proof of Member eligibility.
N.. “Intermediate Care Facility” shall mean a facility which is licensed as such by DHCS or is a hospital or Skilled Nursing Facility which meets the standards specified in 22 CCR, § 51212 and has been certified by DHCS for participation in the Medi-Cal program.
O. “Interpreter” shall mean a person fluent in English and in the necessary second language, who has been assessed and is qualified as someone who can accurately speak, read, and readily interpret the necessary second language, or a person who can accurately sign and read sign language.
P. “Limited English Proficient Member (LEP)” shall mean Members who are limited-English-speaking or non-English-speaking including those who speak a language other than a threshold language, as defined herein.
Q. "Long-Term Care Services" shall mean any sub-acute level inpatient services, including but not limited to the following: Skilled Nursing Facilities Services, Intermediate Care Facilities Services, Extended Care Services, and Sub-Acute Level Services.
R. "May" is used to indicate a permissive or discretionary term or function.
S "Medi-Cal Benefits" shall mean those Inpatient, Outpatient, and Emergency Services for which Medi-Cal Members are eligible pursuant to Welfare and Institutions Code, Sections 14000 et seq. and regulations promulgated thereto, and all other services designated by the PLAN. Also may be referred to as "Covered Service".
T. "Medical Director" shall mean the PLAN’s Medical Director.
U. “Medi-Cal Rates” shall mean the schedule of Medi-Cal maximum allowances and rates of payment for services in effect for California’s Medi-Cal Program at the time the services were rendered.
V “Medical Interpreter” shall mean a person fluent in English and in the necessary second language, who is qualified due to having been trained to provide language services at medical points of contact with language proficiency related to clinical settings.
W. “Medically Necessary” means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.
X “Medical Record” means any record kept or required to be kept by any Facility that documents all the medical services received by the Member, including without limitation inpatient, outpatient, emergency care, referral requests and authorizations, including:
(a) Member identification on each page;
(b) Personal/biographical data in the record;
(c) All entries dated and author identified; the entries will include at a minimum, the subjective complaints, the objective findings, and the plan for diagnosis and treatment;
(d) List of chronic problems and/or significant conditions, a complete record of immunizations and health maintenance or preventive services rendered;
(e) Allergies and adverse reactions prominently noted in the record;
(f) All informed consent documentation, including the human sterilization consent procedures required by Title 22, Sections 51305.1 through 51305.6, if applicable;
(g) All consultations, referrals, and specialists' reports and all pathology and laboratory reports. Any abnormal results will have an explicit notation in the record;
(h) Documentation for Medical Records of adults regarding whether the individual has been informed and has executed an advanced directive such as a Durable Power of Attorney for Health Care; and
(i) Request for/or refusal of language/interpretation services.
Y. “Member" shall mean any person certified as eligible for the Medi-Cal Program, pursuant to Welfare and Institutions Code, Sections 14016 and 14018, whose designated County Code number in the Medi-Cal Eligibility Data System (MEDS) database is "41 and Plan number 503", and whose Aid Code is included for capitation payment in the PLAN's contract with the State of California.
Z “Non-Medical Interpreter” shall mean a person fluent in English and the necessary second language, who is qualified due to having been trained to provide language services at non-medical points of contact with language proficiency related to the specific setting or circumstance.
AA. “Nursing Facility” shall mean a facility that is licensed as either a Skilled Nursing Facility or an intermediate care facility.
BB. “Physician” shall mean an individual licensed to practice medicine or osteopathy in accordance with applicable California law.
CC. “San Mateo County” shall also be referred to as “County”.
DD. "Shall" is used to introduce an obligation of either the PLAN or the NURSING FACILITY, and is mandatory.
EE. “Skilled Nursing Facility” shall mean any institution, place, building, or agency which is licensed as a Skilled Nursing Facility by DHCS or is a distinct part or unit of a hospital, meets the standard specified in 22 CCR § 51215 (except that the distinct part of a hospital does not need to be licensed as a Skilled Nursing Facility) and has been certified by DHCS for participation as a Skilled Nursing Facility in the Medi-Cal program. The term "Skilled Nursing Facility" shall include the terms "skilled nursing home", "convalescent hospital", "nursing home", or "Nursing Facility".
FF. "Skilled Nursing Facility Level of Care" means that level of care provided by a Skilled Nursing Facility meeting the standards for participation as a provider under the Medi-Cal program as set forth in 22 CCR § 51215.
GG. "Special Member" shall mean a member of the PLAN who has not selected or is not assigned to a Contracting Primary Care Physician and who is designated a Special Member by the PLAN.
HH. "State" shall mean the California Department of Health Care Services, Department of Managed Health Care, the California Department of Health and Human Services, and/or the United States Department of Health and Human Services.
II. “Threshold Language” shall mean primary languages spoken by Limited English Proficiency (LEP) population groups meeting a numeric threshold of 3,000 eligible Members residing in a county. Additionally, languages spoken by a population of eligible LEP Members residing in a county, who meet the concentration standard of 1,000 in a single ZIP code or 1,500 in two contiguous ZIP codes, are also considered threshold languages for a county. Threshold languages in each county are designated by the California Department of Health Care Services.
JJ. “Utilization Management (UM)” shall mean those review processes and procedures which are designed to determine whether services are Covered Services or medically necessary and which all Contracting Providers must follow.
ARTICLE II
NURSING FACILITY PERFORMANCE PROVISIONS
A. Services Provided by the NURSING FACILITY. The NURSING FACILITY shall provide Covered Services to Members, subject to the availability of appropriate Nursing Facility services and subacute care services.
B. Admission of Members to NURSING FACILITY for Covered Services shall be based upon the severity of medical need and the availability of skilled nursing facility services, intermediate care facility services, subacute care services, intermediate care facility/developmentally disabled/rehabilitative services, and/or and contingent upon receiving prior authorization. Admission to Facility shall be initiated by the Member’s Physician Group, Primary Care Physician (PCP) or designee and shall require authorization.
C. Availability of Services.
(1) The NURSING FACILITY shall not differentiate or discriminate in the treatment of Medi-Cal Members, nor shall the NURSING FACILITY discriminate on the basis of sex, race, creed, color, ancestry, religious creed, national origin, marital status, sexual orientation, physical disability including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), mental or developmental disability, age, medical condition or mental status, except as limited by the scope of services NURSING FACILITY is qualified to provide. NURSING FACILITY shall render health services to Members in the same manner, with the same dignity and respect, in accordance with the same standards and within the same time availability as offered NURSING FACILITY’s other patients, except as limited by existing Medi-Cal restrictions.
(2) Throughout the term of this Agreement and subject to the conditions within the Agreement, the NURSING FACILITY shall use its best efforts to maintain its current facilities, equipment and patient service personnel (as well as allied health personnel), as the NURSING FACILITY, in its reasonable discretion, may employ, to meet the NURSING FACILITY’s obligation to provide Medi-Cal Benefits hereunder.
D. Standards of Care. The NURSING FACILITY shall, in rendering services to Medi-Cal Members, provide care in accordance with recognized NURSING FACILITY and professional standards and applicable State licensing laws and regulations.
E. Emergency Services. Facility shall seek Emergency Services for Members when Medically Necessary. Facility shall not be responsible for the payment, quality, or use of emergency services by such Members.
G. The PLAN Not to Interfere with the NURSING FACILITY. The PLAN and the NURSING FACILITY agree that the PLAN is responsible for paying for medical care, and that NURSING FACILITY is responsible for providing service to PLAN Members. However, except in emergencies, the NURSING FACILITY shall not be entitled to reimbursement for any services provided to a Member unless the NURSING FACILITY has obtained the necessary authorization from the PLAN in accordance with the PLAN's procedures. The Member's Attending Physician shall determine the need for acute care in accordance with national, professionally recognized standards of medical practice, and Member's Attending Physician shall decide the course of treatment which is medically necessary. Plan reserves the right to coordinate care and collaborate with plan members’ attending physician and interdisciplinary team in medical management/case management.
H. Licensure and Certification. The NURSING FACILITY hereby represents and warrants that it is currently, and for the duration of this Agreement shall remain, licensed as a Skilled Nursing Facility, and NURSING FACILITY hereby represents and warrants that it is currently, and for the duration of this Contract shall remain, licensed in accordance with the California Health and Safety Code and the applicable licensing regulations contained in Title 22, Division 5. i (2) If NURSING FACILITY receives written notice (1) from the State that the State intends to revoke or suspend or has revoked or suspended NURSING FACILITY’s license; or (2) from the State that it will impose or has imposed suspension of admissions or denial of payment for new or all admissions, NURSING FACILITY shall notify PLAN of the receipt of such notice by the close of business of the next business day following NURSING FACILITY’s receipt of such notice. Upon notice, Facility shall treat all Members consistent with other residents in NURSING FACILITY including directives from the State on discharge planning and reimbursement rates.
In the event that NURSING FACILITY receives such a notice, PLAN may impose corrective action plans, terminate this Contract and/or take other appropriate action in accordance with this Contract and PLAN Policies based on the action taken by the State. NURSING FACILITY shall comply with all directives, requirements and/or obligations imposed by the State (and State and Federal law) related to continuity of care and discharge/transfer of Members in such cases. PLAN may take any other action that is consistent with, and/or required by, such State action.
I. Utilization Controls. With the sole exception of emergency services as set forth in the following paragraph, the PLAN shall not be obligated to pay the NURSING FACILITY for any services provided to a Member unless the NURSING FACILITY adheres to all Utilization Management requirements and obtains prior authorization for services in accordance with Medi-Cal policy and procedures as defined in Title 22, State Fiscal Intermediary Provider Manual and Bulletins, and as specifically modified by the PLAN issued Provider Manual and Bulletins.
J. Fraud, Waste, and Abuse Reporting. NURSING FACILITY shall report to PLAN all cases of suspected fraud, waste, and/or abuse, as defined in 42 CFR §455.2, and 42 CFR §423.504(b)(4)(vi)(H), relating to the rendering of Covered Services by NURSING FACILITY, Contracted Providers, Members, or NURSING FACILITY employees and Downstream Entities, within ten (10) working days of the date when Facility first becomes aware of or is on notice of such activity.
K. Member Visits. NURSING FACILITY shall ensure that, pursuant to Health and Safety Code section 1250, it permits a Member, at Member’s choice to be visited by a Member’s domestic partner, the children of a Member’s domestic partner, and the domestic partner of the Member’s parent or children. NURSING FACILITY shall include the requirement of this section in its Downstream Entity contracts.
ARTICLE III
A. Payment Obligation. The PLAN shall pay the NURSING FACILITY those amounts set forth and in the manner and at the times as specified in Exhibit 1, p for Medi-Cal Benefits provided to Members hereunder.
B. Eligibility Verification. The PLAN shall reimburse the NURSING FACILITY for Covered Services properly authorized for any person certified as eligible for the Medi-Cal Program pursuant to Welfare and Institutions Code, Sections 14016 et seq. and whose designated County Code Number in the MEDS database is "41 and whose plan number is 503" and whose Aid Code is included for the capitation payment in the PLAN's contract with the State of California. Eligible Members shall include individuals whose eligibility is not determined until after the rendition of Covered Services to individual by the NURSING FACILITY.
C. Policies and Procedures Availability. PLAN shall provide or make available for NURSING FACILITY copies of current PLAN Policies and Procedures relevant to the provisions of this Contract. Copies of current PLAN Policies and Procedures relevant to the provisions of this Contract may be provided by the distribution of hard-copy documents, electronic files and/or documents and/or on the PLAN website.
D. Release of Performance Information and Data. Facility acknowledges and agrees that PLAN may release to providers, Members and others, without further notice to NURSING FACILITY, information and data relating to the performance of NURSING FACILITY that PLAN determines would contribute to providers’, Members’ and others’ evaluation of options and alternatives and/or making informed decisions regarding health care and the provision of Covered Services.
ARTICLE IV
A. NURSING FACILITY Services. The PLAN shall pay to the NURSING FACILITY, and the NURSING FACILTY shall accept from the PLAN in full and final satisfaction of the PLAN's reimbursement obligation for Medi-Cal Benefits provided to Members by the NURSING FACILITY hereunder, those amounts set forth and in the manner and at the times as specified in Exhibit 1 to this Agreement.
B. Medi-Cal Member Billing. The NURSING FACILITY shall not submit claims to demand, or otherwise collect reimbursement from a Medi-Cal Member, or from other persons on behalf of the Member, for any service included in the Medi-Cal Program's Scope of Benefits in addition to a claim submitted to the PLAN for that service, except to:
(1) Collect payments due under a contractual or legal entitlement pursuant to Section 14000 (b) of the Welfare and Institutions Code;
(2) Collect co-payment pursuant to Welfare and Institutions Code Section 14134.
C Member Hold Harmless. The NURSING FACILITY agrees to hold harmless the Member in the event the PLAN cannot or will not pay for services rendered or materials provided by the NURSING FACILITY pursuant to the terms of this Agreement.
ARTICLE V
A. Coordination of Benefits. The NURSING FACILITY shall use its reasonable efforts to collect monies due and owing, for health care services provided to a Member, from the Federal Medicare Program, Kaiser Permanente, Ross-Loos, the TRICARE/CHAMPUS Program and Health Maintenance Organizations and other private health insurance plans when the NURSING FACILITY has knowledge that a Patient is a Member of one of the foregoing programs or plans. In the event the NURSING FACILITY collects monies from one of the foregoing entities listed in this Article VI A, the NURSING FACILITY shall notify the PLAN and the PLAN's obligation hereunder shall be reduced by the amount actually collected by the NURSING FACILITY. No adjustment shall be made for any amounts which the NURSING FACILITY is unable to collect.
B. Billing Procedures. Completed claims submitted by the NURSING FACILITY to the PLAN shall be paid by the PLAN in accordance with existing Medi-Cal policies as evidenced in Title 22, State Fiscal Intermediary Provider Manual and Bulletins, and as modified by the PLAN issued Provider Manual and Bulletins.
C. Member Notification. The NURSING FACILITY shall comply with existing State and Federal law and regulations promulgated thereto pertaining to the issuance of explanations of benefits for Members.
ARTICLE VI
A. PLAN Insurance. The PLAN, at its sole cost and expense, shall procure and maintain a professional liability policy in the amount of $1,000,000.00 to insure the PLAN and its agents, and employees, acting within the scope of their duties, against any claims for personal injury or death occasioned directly or indirectly by the PLAN or by its agents, or employees in connection with the performance of the PLAN's responsibilities under this Agreement.
B. Professional Liability Insurance. NURSING FACILITY, at its sole cost and expense, shall ensure that it and any Downstream Entities providing Covered Services for Members shall maintain a professional liability insurance policy (Medical Malpractice) with minimum per incident and annual aggregate amounts which are at least equal to the community minimum amounts in San Mateo County, California, for the specialty or type of service which Facility provides, with a minimum of $1,000,000 per incident/$3,000,000 aggregate per year.
C. Comprehensive General Liability and Automobile Liability Insurance. NURSING FACILITY at its sole cost and expense shall maintain such policies of comprehensive general liability and automobile liability insurance and other insurance as shall be necessary to insure it and its employees, agents, and representatives against any claim or claims for damages arising by reason of a) personal injuries or death occasioned in connection with the performance of any Covered Services provided hereunder, b) the use of any property of Facility, and c) activities performed in connection with the Contract. Facility shall maintain comprehensive general liability and automobile liability insurance with a minimum of $1,000,000 per incident/$3,000,000 aggregate per year.
D. Workers Compensation Insurance. Facility at its sole cost and expense shall maintain Workers Compensation Insurance within the limits established and required by the State of California and employers liability insurance with minimum limits of liability of $1,000,000 per occurrence/$1,000,000 aggregate per year.
E Proof of Insurance. Memorandum copies of all the above insurance policies and/or evidence of self-insurance shall be provided to PLAN upon request.
F. Material Change. Facility shall not of its own initiative cause such insurances as addressed in this Article to be canceled or materially changed during the term of this Contract.
G NURSING FACILITY Indemnification. The NURSING FACILITY agrees to indemnify, defend and hold harmless the PLAN, its agents, officers and employees from and against any and all liability, expense, including defense costs and legal fees, and claims for damages of any nature whatsoever, including, but not limited to, bodily injury, death, personal injury, or property damage arising from or connected with the NURSING FACILITY’S operations or its services hereunder. This provision is not intended to nor shall it be construed to require the NURSING FACILITY to indemnify the PLAN for any PLAN liability independent of that of the NURSING FACILITY, nor to cause the NURSING FACILITY to be subject to any liability to any third party (either directly, or as an indemnitor of the PLAN or its agents, officers, and employees) in any case where the NURSING FACILITY liability would not otherwise exist. Rather, the purpose of this provision is to assure that the PLAN and its agents, officers, and employees, will be provided with indemnification for and a defense to any vicarious or other indirect liability or claim against the PLAN or such agents, officers, or employees resulting from the actions or other omissions of the NURSING FACILITY in connection with the NURSING FACIITY’S operations or its services under this Agreement.
H. PLAN Indemnification. The PLAN agrees to indemnify, defend and hold harmless the NURSING FACILITY, its agents, officers and employees from and against any and all liability, expense, including defense costs and legal fees, and claims for damages of any nature whatsoever, including, but not limited to, bodily injury, death, personal injury, or property damage arising from or connected with the PLAN's operations or its services hereunder. This provision is not intended to nor shall it be construed to require the PLAN to indemnify the NURSING FACIITY for any NURSING FACILITY liability independent of that of the PLAN, nor to cause the PLAN to be subject to any liability to any third party (either directly, or as an indemnitor of the NURSING FACILITY or its agents, officers, and employees) in any case where the PLAN liability would not otherwise exist. Rather, the purpose of this provision is to assure that the NURSING FACILITY and its agents, officers, and employees, will be provided with indemnification for and a defense to any vicarious or other indirect liability or claim against the NURSING FACILITY or such agents, officers, or employees resulting from the actions or other omission of the PLAN in connection with the PLAN's operations or its services (including utilization review services) under this Agreement.
ARTICLE VII
A. Inspection Rights
(1) The NURSING FACILITY shall make all of its books and records, pertaining to the goods and services furnished under the terms of this Agreement, available for inspection, examination or copying:
(a) By the PLAN, or any entity designated by the PLAN (e.g. for HEDIS data collection), the State Department of Health Care Services, the State Department of Managed Health Care, and the United States Department of Health and Human Services, and all applicable state and federal agencies, and self regulatory agencies.
(b) Upon reasonable notice and at all reasonable times at the NURSING FACILITY or at such other mutually-agreeable location in California.
(c) In a form maintained in accordance with the general standards applicable to such book or record keeping.
(d) For a term of at least ten (10) years from the close of the State’s fiscal year in which this Agreement was in effect. The requirement to maintain records shall remain in effect even upon the termination of this Agreement.
(2) These audits or reviews may evaluate factors including but not limited to the following issues pertinent to Medi-Cal Members:
(a) Level and quality of care, and the necessity and appropriateness of the services provided.
(b) Internal procedures for assuring efficiency, economy, and quality of care.
(c) Grievances relating to medical care and their disposition.
(d) Financial records when determined necessary by the PLAN to assure accountability for public funds.
(3) The parties agree that the purpose of the audits and reviews authorized by this Paragraph VIII A is solely to assess the NURSING FACILITY and the NURSING FACILITY’s subcontract's compliance with the terms and conditions of this Agreement.
(4) NURSING FACILITY does not waive the provisions of Evidence Code 1157 with regard to Medical Staff records.
B. Records to be Kept; Audits or Review; Availability; Period of Retention.
(1) The NURSING FACILITY shall maintain books, records, documents, and other evidence, using accounting procedures and practices sufficient to reflect properly all direct and indirect costs of whatever nature claimed to have been incurred in the performance of this Agreement in accordance with generally accepted accounting principles.
(2) The NURSING FACILITY shall maintain the above information in accordance with Medicare principles of reimbursement, and shall be consistent with the requirements of the California Health Facilities Commission. In cases where any of the above requirements are in conflict, the NURSING FACILITY 's compliance with any one of such requirements is sufficient.
(3) The NURSING FACILITY shall maintain medical records required by Sections 70747-70751 of Title 22 of the California Code of Regulation, and other records related to a Member's eligibility for services, the service rendered, the Member to whom the service was rendered, the date of the service, the medical necessity of the service and the quality of the service provided. Records shall be maintained in accordance with Section 51476 of Title 22 of the California Administrative Code. The foregoing constitutes "records" for the purposes of this Paragraph.
C. NURSING FACILITY’s Subcontracts. The NURSING FACILITY shall maintain and make available to the PLAN, the U.S. Department of Health and Human Services, Department of Managed Health Care, the State Department of Health Care Services, or any other regulatory oversight agency upon written request, copies of all subcontracts for the performance of any of the NURSING FACILITY's obligations under this Agreement. The NURSING FACILITY shall further assure that all subcontracts entered into from the effective date of this Agreement shall require that the Downstream Entity:
(1) Make all applicable books and records available at all reasonable times for inspection, examination, or copying by the PLAN, the Department of Managed Health Care, the above named State agencies, all applicable state and federal agencies, and self regulatory agencies.
(2) Retain such books and records for a term of ten (10) years from the close of the State’s fiscal year in which the subcontract became effective.
D. Confidentiality of Member Information. Notwithstanding any other provision of this Agreement, names of Members receiving public social services hereunder are confidential and are to be protected from unauthorized disclosure in accordance with Title 42, Code of Federal Regulations, Section 431.300 et seq. and Section 14100.2 of the Welfare and Institutions Code and regulations adopted hereunder. For the purpose of this Agreement, all information, records, payment information, data and data elements collected and maintained for the operation of the Agreement and pertaining to Members shall be protected by the NURSING FACILITY from unauthorized disclosure as required by Medi-Cal and any applicable law.
E. Third-Party Liability. The NURSING FACILITY shall report to the PLAN, when the NURSING FACILITY discovers that Medi-Cal Benefits rendered either directly by the NURSING FACILITY or through the instrumentality of a NURSING FACILITY Downstream Entity are covered, in whole or in part, by workers' compensation, tort liability, or casualty insurance. Nothing contained herein shall be construed to reduce or modify the NURSING FACILITY's obligation to reimburse the PLAN for Medi-Cal Benefits rendered to a Member.
ARTICLE VIII
A. Patient Rights. The NURSING FACILITY or any Downstream Entity performing the obligations of the NURSING FACILITY pursuant to the terms of this Agreement shall adopt and post in a conspicuous place a written policy on patient's rights in accordance with Section 70707 of Title 22 of the California Code of Regulations.
B. Linguistic Services and Cultural Sensitivity
1. Interpreter Services for Limited English Proficient (LEP) Members
The NURSING FACILITY shall ensure equal access to health care services for all Limited English Proficient (LEP) members through the utilization of qualified interpreter services at medical (advice, face-to-face or telephone encounters), and non-medical (appointment services, reception) points of contact.
a) Qualified interpreter services shall be furnished during encounters with providers (physicians, physician extenders, registered nurses, or other personnel) who provide medical or health care advice to Members, when identified by a Provider or requested by a Member.
i. Qualified interpreter services may be obtained through on-site trained interpreters, bilingual or multilingual providers. NOTE: The use of ad hoc interpreters (e.g. family members, friends) is not to be recommended per state and federal regulations, and is only to be used if a Member insists on this after provider explanation that ad hoc interpreters have been demonstrated in clinical studies to lead to lower quality of care due to errors in translation.
b) The NURSING FACILITY must document the patient’s preferred language, the request/type of interpreter services provided or refusal of language interpreter services by a Limited English Proficient (LEP) Member in the medical record.
c) NURSING FACILITY should utilize bilingual staff and/or the PLAN’s interpreter services to ensure that Limited English Proficient members receive timely interpretation services at no charge and at all points of contact. This ensures that members are not subjected to unreasonable delays in receiving services.
2. Additional Linguistic Services for Threshold Language Members
Threshold languages in each county are designated by the State Department of Health Care Services. These are primary languages spoken by the LEP population groups meeting a specific numeric threshold or concentration standard. The threshold language for San Mateo County is published annually.
In addition to interpreter services for LEP members as stated in section B1, the NURSING FACILITY shall provide the following services for Members whose language proficiency is in a threshold language.
a) Translated signage;
b) Translated written materials; and
c) Referrals to culturally and linguistically appropriate community service programs.
d) Information on how to file a grievance and the ability to file a
grievance in a non-English language.
The NURSING FACILITY may request assistance from the PLAN in meeting these requirements.
3. NURSING FACILITY shall comply with all of the following requirements related to the provision of linguistic and culturally sensitive services in accordance with this Agreement and PLAN Policies.
NURSING FACILITY shall address the special health care needs of all Members. NURSING FACILITY shall ensure equal access and participation in federally funded programs to Members with Limited English Proficiency (LEP) or hearing, speech or vision impairment through the provision of bilingual services. NURSING FACILITY shall in policies, administration, and services practice the values of: (a) honoring the Member's beliefs, traditions and customs; (b) recognizing individual differences within a culture; (c) creating an open, supportive and responsive organization in which differences are valued, respected and managed; (d) through cultural diversity training, fostering in staff and Contracting Providers attitudes and interpersonal communication styles which respect Member's cultural backgrounds and are sensitive to their special needs; and (e) referring Members to linguistically and culturally sensitive programs.
ARTICLE IX
TERM, TERMINATION, AND EFFECT OF TERMINATION
A. Term. The term of this Agreement shall commence on February 1, 2010 and shall terminate on January 31, 2011.
This Agreement will automatically renew for successive twelve (12) month periods on the same terms and conditions (including subsequent amendments) unless terminated pursuant to the terms of this Agreement.
B. Termination Without Cause. The NURSING FACILITY or the PLAN may terminate this Agreement without cause upon providing the other party with ninety (90) days prior written notice.
C. Termination for Material Breach. Either party shall have the right to terminate this Agreement upon providing thirty (30) days prior written notice to the other party if the party to whom such notice is given is in material default under this Agreement. The party claiming the right to terminate hereunder shall set forth in the notice of intended termination required hereby the effective date of such termination and the facts underlying its claim that the other party is in breach of this Agreement. If the NURSING FACILITY or the PLAN remedies such alleged breach within twenty (20) days of the receipt of such notice, the Agreement shall remain in effect for the remaining term and such termination notice shall no longer be in effect. Notwithstanding the other provisions of this paragraph, the PLAN may immediately suspend this Agreement pending completion of applicable termination procedures, if the PLAN makes a reasonable determination, supported by written findings, that the health and welfare of Members is jeopardized by continuation of the Agreement.
D. Termination Based upon Unforeseen Events. In the event there are (1) changes effected in the PLAN's contract with the State of California, or (2) changes effected in the Medi-Cal Program, or changes in Federal laws governing the Medi-Cal Program, or (3) changes in the Federal Medicare Program and/or substantial changes under other public or private health and/or hospital care insurance programs or policies which will have a material detrimental financial effect on the operations of the NURSING FACILITY or the PLAN, the NURSING FACILITY or the PLAN may terminate this Agreement upon providing the other party with thirty (30) days prior written notice. In any case where such notice is provided, both parties shall negotiate in good faith during such thirty (30) day period in an effort to develop a revised Agreement, which, to the extent reasonably practicable, under the circumstance, will adequately protect the interests of both parties in light of the governmental program or private insurance policy changes which constituted the basis for the exercise of this termination provision.
E. Termination by U.S. Department of Health and Human Services or the State Department of Health Care Services. If the qualification of the NURSING FACILITY under the Federal Social Security Act is terminated or ceases for any reason or if the PLAN's Medi-Cal Services Contract with the State of California is terminated or ceases for any reason, the PLAN shall give the NURSING FACILITY immediate written notice of the foregoing termination(s) and this Agreement shall terminate in accordance with the terms under D of this Article.
F. Effect of Termination. As of the date of termination pursuant to any provision of this Agreement, this Agreement shall be of no further force or effect whatsoever, and each of the parties hereto shall be relieved and discharged herefrom, except that the PLAN shall remain liable for payment for all Medi-Cal Benefits rendered to PLAN’s Medi-Cal Members up to the date of termination and for any Medi-Cal Benefits rendered hereunder after such date until such time as appropriate transfer (or other medically acceptable disposition) of Medi-Cal Members receiving inpatient services as of the date of termination is achieved.
G. Termination for Interruption. The PLAN may terminate Agreement upon ten (10) days written notice pursuant to Article XI.
H. Amendments to Avoid Termination. If the provisions of Article X D of this Agreement are invoked, the party who invokes them shall make all reasonable efforts, if so requested by the other party, to negotiate amendments to this Agreement which will bring the terms of the Agreement in compliance with such statute, regulation, or judicial decision.
I Notification of Department of Health Care Services (DHCS). NURSING FACILITY agrees to notify DHCS in the event this Agreement with PLAN is terminated. Notice is considered given when properly addressed and deposited in the United States Postal Service as first-class registered mail, postage attached.
ARTICLE X
Cause Beyond Control of the NURSING FACILITY. In the event the operations of the NURSING FACILITY, or any substantial portion thereof, are interrupted by war, fire, insurrection, riots, the elements, earthquakes, acts of God, or without limiting the foregoing, any other cause beyond the control of the NURSING FACILITY, the NURSING FACILITY shall be relieved of its obligations with respect to the provisions of this Agreement (or such portions hereof which the NURSING FACILITY is thereby rendered incapable of performing) for the duration of such interruptions. Nothing contained herein shall be construed to limit or reduce the PLAN's obligation to pay the NURSING FACILITY for Medi-Cal Benefits rendered to Members prior to or subsequent to an event described herein. Should a substantial part of the services which the NURSING FACILITY has agreed to provide hereunder be interrupted for a period in excess of thirty (30) days, the PLAN shall have the right to terminate this Agreement upon providing ten (10) days prior written notice to the NURSING FACILITY.
ARTICLE XI
A. Applicability of State and Federal Laws and Regulations. This Agreement shall be governed and construed in accordance with the laws of the State of California and of the United States. Any provision of this Agreement which is in conflict with, or does not conform to applicable State or Federal statutes or regulations promulgated pursuant thereto shall be amended to conform to the requirements of such statutes or regulations.
B. Severability. In the event any provision of this Agreement is rendered invalid or unenforceable by Act of Congress, by statute of the State of California, by any regulation duly promulgated by the United States or the State of California in accordance with law or is declared null and void by any court of competent jurisdiction, the remainder of the provisions hereof shall remain in full force and effect.
C. Limitation of Severability. In the event the removal of a provision rendered invalid or unenforceable or declared null and void has the effect of materially altering the obligations of either party in such manner as to cause serious financial hardship to such party, the party so affected shall have the right to terminate this Agreement upon providing thirty (30) days prior written notice to the other party.
D. Contract Approval by Department of Health Care Services. PLAN affirms that a provider or management contract entered into by PLAN which is not a federally qualified HMO shall become effective upon approval by DHCS in writing, or by operation of law where DHCS has acknowledged receipt of the proposed contract, and has failed to approve or disapprove the proposed contract within 60 calendar days of receipt.
E. Contract Amendments. Contract amendments shall be submitted to DHCS for prior approval at least 30 calendar days before the effective date of any proposed changes governing compensation, services, or term. Proposed changes which are neither approved or disapproved by DHCS shall become effective by operation of law 30 calendar days after DHCS has acknowledged receipt or upon the date specified in the contract amendment, whichever is later.
F. Public Records. This Agreement and all information received in accordance with this subsection will be public records on file with DHCS, except as specifically exempted in statute. DHCS shall ensure the confidentiality of information and contractual provisions filed with DHCS to the extent they are specifically exempted by statute from disclosure, in accordance with the statutes providing the exemption. The names of the officers and owners of NURSING FACILITY, stockholders owning more than five (5) percent of the stock issued by NURSING FACILITY and major creditors holding more than five (5) percent of the debt of NURSING FACILITY will be attached to this Agreement at the time this Agreement is presented to DHCS.
ARTICLE XII
GRIEVANCES AND DISPUTE RESOLUTIONS
A. Grievance and Dispute Resolutions. It is understood that the NURSING FACILITY may have Grievances and Dispute Resolutions which may arise as a health care Provider under contract with the PLAN. These Grievances and Dispute Resolutions shall be resolved through the mechanisms set out in this section. NURSING FACILITY and the PLAN shall be bound by the decisions of the PLAN’s Grievances and Dispute Resolution mechanisms.
B. Disputes. It is understood that the NURSING FACILITY may have disputes which may arise as a health care Provider under contract with the PLAN. These disputes shall be resolved through the mechanisms set out in this section. NURSING FACILITY and the PLAN shall be bound by the decisions of the PLAN’s Grievances and Dispute Resolution mechanisms.
C. PLAN Grievances and Dispute Resolution Procedure Responsibility. The PLAN’s Executive Director has primary responsibility for maintenance, review, formulation of policy changes, and procedural improvements of the Grievances and Dispute Resolution review system. The Executive Director shall be assisted by other PLAN staff as requested.
D. Resolution of Member and Provider Initiated Grievances or Dispute Resolution at PLAN Level. The NURSING FACILITY agrees that all disputes or disagreements between the NURSING FACILITY and the PLAN or the Member shall be resolved in accordance with the Provider Manual, PLAN policies and State guidelines and regulations. NURSING FACILITY agrees to cooperate with PLAN in resolving Member grievances and/or appeals related to the NURSING FACILITY. PLAN will bring to the NURSING FACILITY attention all Member complaints involving NURSING FACILITY. NURSING FACILITY will, in accordance with PLAN approved procedures, investigate such complaints and use their best efforts to resolve them in a fair and equitable manner. NURSING FACILITY shall immediately make available to PLAN, any and all records, notes, and documents or other information regarding NURSING FACILITY’s dispute resolution mechanism and the resolution of any and all disputes with Members. If a Member files a complaint at the NURSING FACILITY Level, NURSING FACILITY agrees to send to the PLAN’s Grievances and Appeals Coordinator, a quarterly report, containing the Member’s name, PLAN ID Number, date of complaint or grievance, type of complaint or grievance, category, and the resolution.
E. Dispute Resolution. The NURSING FACILITY agrees that all disputes between the NURSING FACILITY and the PLAN shall be resolved in accordance with the Provider Manual, PLAN policies and State guidelines and regulations. PLAN retains responsibility for dispute resolution and does not delegate it to NURSING FACILITY. PLAN agrees to cooperate with NURSING FACILITY in resolving disputes. PLAN will investigate such disputes and use their best efforts to resolve them in a fair and equitable manner that is acceptable to PLAN and NURSING FACILITY. NURSING FACILITY agrees to notify PLAN promptly of any action taken or proposed with respect to the resolution of such disputes and the avoidance of similar disputes in the future. NURSING FACILITY shall immediately make available to PLAN, any and all records, notes, and documents or other information regarding NURSING FACILITY’s dispute resolution mechanism.
ARTICLE XIII
A. Time of the Essence. Time shall be of the essence of each and every term, obligation, and condition of this Agreement.
B. Entire Agreement. This Agreement (together with all Exhibits hereto) contains the entire Agreement between the parties relating to the rights herein granted and the obligations herein assumed. It is the express intention of the NURSING FACILITY and the PLAN that any and all prior or contemporaneous agreements, promises, negotiations or representations, either oral or written, relating to the subject matter and period governed by this Agreement which are not expressly set forth herein shall be of no further force, effect or legal consequence after the effective date hereunder.
C. Amendments. This Agreement and any Exhibits hereto may be amended only by an instrument in writing, duly executed by both parties hereto in accordance with applicable provisions of the Knox-Keene Health Service Plan Act of 1975, as amended, and the regulations promulgated hereunder by the Department of Managed Health Care.
D. Waivers. No obligation under this Agreement or an Exhibit hereto may be waived by any party hereto except by an instrument in writing, duly executed by the party waiving such obligations. All manners shall specify the provisions being waived, and no waiver of any provision of this Agreement extends or implies the extension of the waiver to any other provisions of this Agreement unless so specified in writing.
E. Independent Contractors. The PLAN and the NURSING FACILITY hereby acknowledge that they are independent contractors and neither is an officer, agent or employee of the other for any purpose.
F. Counterparts. This Agreement may be executed in counterparts, each of which shall be considered to be an original; however, all such counterparts shall constitute but one and the same Agreement.
G. Headings. The headings or titles of articles and sections contained in this Agreement are intended solely for the purpose of facilitating reference, are not a part of the Agreement and shall not affect in any way the meaning or interpretation of this Agreement.
H. Inurement. This Agreement shall be binding upon all assignees, heirs and successors-in-interest of either party.
I. Assignment. Neither the PLAN nor the NURSING FACILITY shall assign this Agreement without the written consent of the other party.
ARTICLE XIV
A. Any notice required to be given pursuant to the terms and provisions hereof, unless otherwise indicated herein, shall be in writing and shall be sent by certified mail, return receipt requested, postage prepaid, or courier service (Airborne, Federal Express, UPS, etc.) or other means which can provide written proof of delivery, to the PLAN at:
Health Plan of San Mateo
701 Gateway Blvd., Suite 400
South San Francisco, CA 94080
Attn: Executive Director
and
NURSING FACILITY at:
_____________________
_____________________
_____________________
Attn: _______________
Health Plan of San Mateo
Dated: ________________ By: _________________________________________
Maya Altman, Executive Director
NURSING FACILITY
Name ________________________________________
Dated: ________________ By: ________________________________________
Title: ________________________________________
1. Protocols for Nursing Facility
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