NC DHHS Agreement for Participation as a CCNC/CA Provider

This Agreement is between the State of North Carolina, Department of Health and Human Services Division of Health Benefits, whose principal office is located in the City of Raleigh, County of Wake, State of North Carolina, hereinafter referred to as the “Division”

and *                                  (Name of Primary Care Provider) located in the city of *                                           , county of *                                                                             , State of North Carolina or State of                                                                             

hereinafter referred to as the “Provider.”

 

WHEREAS, the Division, as the State agency designated to establish and administer a program to provide medical assistance to the indigent under Title XIX of the Social Security Act, is authorized to enter an agreement with health care providers for the provision of such assistance on a coordinated care basis;

 

NOW, THEREFORE, it is agreed between the DIVISION and the PROVIDER, as follows:

 

1. General Statement of Purpose and Intent

The Division desires to enter into this Agreement with providers willing to participate in the North Carolina Medicaid and Health Choice Programs to provide primary care directly and to coordinate other health care needs through the appropriate referral and authorization of Medicaid services. This program, Carolina ACCESS, applies to certain Medicaid beneficiaries who may select or be assigned to the Provider. This Agreement describes the terms and conditions under which this Agreement is made and the responsibilities of the parties thereto.

Except as herein specifically provided otherwise, this Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the Division and the named Provider. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any other third person. It is the express intention of the Division and Provider that any such person or entity, other than the Division or the Provider, receiving services or benefits under this Agreement shall be deemed an incidental beneficiary only.

2. General Statement of the Law

North Carolina's Patient Access and Coordinated Care Program (Carolina ACCESS) is a primary care patient coordination system implemented pursuant to Title XIX of the Social Security Act and is subject to the provisions of North Carolina Statutes and North Carolina Administrative Code. This Agreement shall be construed as supplementary to the usual terms and conditions of providers participating in the Medicaid program, except to the extent superseded by the specific terms of this agreement. The Provider agrees to abide by all existing laws, regulations, rules, policies, and procedures pursuant to the Carolina ACCESS and Medicaid program.

The validity of this Agreement and any of its terms or provisions, as well as the rights and duties of the parties to this Agreement, are governed by the laws of North Carolina. The Provider, by signing this Agreement, agrees and submits, solely for matters concerning this Agreement, to the exclusive jurisdiction of the courts of North Carolina and agrees, solely for such purpose, that the venue for any legal proceedings shall be the county of the Provider.

3. Definitions-The following terms have the meaning stated for the purposes of this Agreement:

Application- All forms and supplements to this Agreement that the provider uses to apply for participation with the Carolina ACCESS program. This Agreement shall be effective subject to approval of the application by the Division.

Beneficiary Disenrollment- The disenrollment of the individual from the Carolina ACCESS program.

C.F.R- Code of Federal Regulations.

Division- The Division of Health Benefits of the North Carolina Department of Health and Human Services.

Eligible Beneficiary- Medicaid beneficiaries who are eligible for enrollment in the Carolina ACCESS program.

Enrollee- A Medicaid beneficiary who chooses or is assigned to a Carolina ACCESS primary care provider.

Organization Practice/Center- A Medicaid participating primary care provider structured as an organization or group practice/center which (1) is a legal entity (e.g., corporation, partnership, etc.), (2) possesses a federal tax identification (employer) number, and (3) is designated as a group by means of a Medicaid Organization Provider number.

Medicaid- The North Carolina Medicaid and Health Choice Programs.

Medically Necessary- The term “Medical Necessity” is defined by Division policy.

Patient Care Coordination- The manner or practice of providing, directing, and coordinating the health care and utilization of health care services of enrollees

Potential Enrollee- A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given managed care program,

Preventive Services- Services rendered for the prevention of disease in adults and children as defined by Medicaid policy.

Primary Care- The ongoing responsibility for directly providing medical care (including diagnosis and/or treatment) to an enrollee regardless of the presence or absence of disease. It includes health promotion, identification of individuals at risk, early detection of serious disease, management of acute emergencies, rendering continuous care to chronically ill patients, and referring the enrollee to another provider when necessary.

Primary Care Provider- The participating physician, physician extender (PA, FNP, CNM), or organization/group practice or center selected by or assigned to the enrollee to provide and coordinate all of the enrollee's health care needs and to initiate and monitor referrals for specialized services when required.

Provider- The Primary Care Provider (PCP) entering into this agreement with the Department of Health and Human Services Division of Health Benefits.

Women, Infants, and Children (WIC) Program- The Special Supplemental Food Program created by Congress in 1972 to meet the special nutritional needs of pregnant, breastfeeding and postpartum women, and of infants and children up to age five (5).

4. Functions and Duties of the Provider

In the provision of services under this Agreement, the Provider and its subcontractors shall comply with all applicable federal and state statutes and regulations, and all amendments thereto, that are in effect when the agreement is signed, or that come into effect during the term of the agreement. This includes, but is not limited to, Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations.

The Provider is and shall be deemed to be an independent contractor in the performance of this Agreement and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Provider represents that it has, or shall secure at its own expense, all personnel required in performing the services under this Agreement. Such employees shall not be employees of or have any individual contractual relationship with the Division.

The Provider shall not subcontract any of the work contemplated under this Agreement without prior written approval from the Division. Any approved subcontract shall be subject to all conditions of this Agreement. Only the subcontractors specified in the Provider’s application are to be considered approved upon award of the contract. The Provider shall be responsible for the performance of any subcontractor. The Division shall not be responsible to pay for work performed by unapproved subcontractors.

The Carolina ACCESS Provider agrees to do the following:

1. 1. Accept enrollees pursuant to the terms of this agreement and be listed as a primary care provider in the Carolina ACCESS program for the purpose of providing care to enrollees and managing their health care needs.
   2. Provide Primary Care and Patient Care Coordination services to each enrollee in accordance with the provisions of this agreement
   3. Provide or arrange for primary care services, consultation, referral, or medical advice to enrolled beneficiaries, twenty-four (24) hours per day, seven (7) days per week. Routine referral to the hospital emergency department does not satisfy this requirement.
   4. Provide direct patient care a minimum of 30 office hours per week.
   5. Provide preventive services as defined by Medicaid policy.
   6. Establish and maintain an arrangement for management of inpatient hospital admissions of enrollees.
   7. Maintain a unified patient medical record for each enrollee.
   8. Promptly arrange referrals for medically necessary health care services that are not provided directly and document referrals for specialty care in the medical record.
   9. Transfer the Carolina ACCESS enrollee's medical record to the receiving Provider upon the change of primary care provider at the request of the new primary care provider and as authorized by the enrollee within 30 days of the date of the request.
   10. Establish and maintain a process for monitoring beneficiary enrollment and practice level utilization management, and advise the Division of errors, omissions, or discrepancies.
2. 11. Participate with Division utilization management, quality assessment, and administrative programs.
   12. Provide the Division or its duly authorized representative or the Federal government unlimited access (including onsite inspections and review) to all records relating to the provision of services under this Agreement as required by Medicaid policy and 42 C.F.R. 431.107.
   13. Refer potentially eligible enrollees to the WIC Program with the enrollee's consent to the release of relevant medical record information.
   14. Maintain reasonable standards of professional conduct and provide care in conformity with generally accepted medical practice following national and regional clinical practice guidelines or guidelines approved by the North Carolina Physicians Advisory Group.
   15. Notify the Division or its agents of any and all changes to information provided on the initial application for participation.
   16. Give written notice of termination of this Agreement, within 15 days after receipt of a termination notice from the Division, or issuance of its termination notice to the Division, to each enrollee who received his or her primary care from or, was seen on a regular basis by, this Provider.
   17. Refrain from discriminating against individuals eligible to enroll on the basis of health status or the need for health care services.
   18. Refrain from discriminating against individuals eligible to enroll on the basis of race, color, or national origin and provide equal treatment of men and women with respect to health coverage.  Refrain from discrimination based on pregnancy, gender identity, and sex stereotyping. Comply with all Federal and State laws and regulations including Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 (regarding education programs and activities), the Age Discrimination Act of 1975, the Rehabilitation Act of 1973 and the Americans with Disabilities Act.
   19. Make oral interpretation services available free of charge to each potential enrollee and enrollee. This applies to all non- English languages.
   20. Receive prior approval from the Division of any marketing materials prior to distribution. Marketing materials shall not make any assertion or statement (whether written or oral) that the beneficiary must enroll with the Provider in order to obtain benefits or in order not to lose benefits. Marketing materials shall not make any assertion or statement that the Provider is endorsed by CMS, the Federal or State government or similar entity.
   21. Refrain from door-to-door, telephonic or other ‘cold-call’ marketing; engaging in marketing activities that could mislead, confuse, or defraud Medicaid beneficiaries, or misrepresent the Provider, its marketing representatives, or the Division.
   22. Refrain from knowingly engaging in a relationship with the following:
       • an individual who is debarred, suspended or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549;
       • an individual who is an affiliate, as defined in the Federal Acquisition Regulation.

Note: The relationship is described as follows:

• • As a director, officer, partner of the Provider,
  • A person with beneficial ownership of more than five percent (5%) or more of the Provider’s equity; or,
  • A person with an employment, consulting or other arrangement with the Provider for the provision of items and services that are material to the Provider’s obligation with the Division.

4. 23. Retain records in accordance with requirements of 45 CFR 164.316  (6 years after the final payment is made and all pending matters closed, plus additional time if an audit, litigation, or other legal action involving the records is started before or during the original 6-year period ends.)
5. Functions and Duties of the Division

The Division, or through its vendors, agrees to do the following:

1. 1. List the Provider’s name as a primary care provider in the Carolina ACCESS program.
   2. Pay the Provider according to Medicaid program guidelines.
   3. Provide technical assistance regarding the Carolina ACCESS program
   4. Publish information and updates related to Medicaid policies and/or guidelines.
   5. Provide an ongoing quality assurance program to evaluate the quality of health care services rendered to enrollees.
   6. Provide program education to all enrollees through the local Department of Social Services or duly authorized representatives during eligibility reviews or within a reasonable timeframe. The beneficiary will receive accurate oral and written information needed to make an informed decision.
   7. Provide potential enrollees and enrollees with a member handbook that contains program information including enrollee rights and protections, program advantages, enrollee responsibilities, complaint and grievance instructions.
   8. Notify enrollees that oral interpretation is available for any language and written material is available in prevalent languages and how to access these services.
   9. Provide written materials that use easily understood language and format. Written material will be available in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency.
   10. Provide marketing materials to potential enrollees.

 

6. General Terms and Conditions
   1. Beneficiary Enrollment and Disenrollment
      1. Beneficiary Enrollment

The Provider must accept individuals in the order in which they apply without restriction up to the limits set by the agreement. The Provider may specify a limit on the number of enrollees on the Carolina ACCESS Application for Participation subject to the following terms and conditions:

• Maximum enrollment is set at 2,000 enrollees per physician or physician extender unless otherwise approved by the Division.
• Notwithstanding the enrollment limits specified above, the Provider may receive an enrollment that slightly exceeds these limits due to the nature and timing of the enrollment process.
• The Provider may change the enrollee limit.
• The Provider must restrict enrollment to beneficiaries who reside within 30 miles of the delivery site to reach that site within 45 minutes, pursuant to beneficiary choice, using available and affordable modes of transportation.

B. Beneficiary Choice

• Eligible beneficiaries may choose from among participating Providers who are available to their county of residence when those Providers’ enrollment limits have not been exceeded.
• Eligible beneficiaries who do not choose a primary care provider shall be assigned to an appropriate participating provider available to their county of residence based on historic usage, location and/or randomly by rotating assignment.
• All beneficiary enrollments, disenrollments and changes are effective on the first day of the month, pursuant to processing deadlines.

 C. Beneficiary Disenrollment

• Enrollees shall be permitted to change primary care providers according to Medicaid program guidelines. Transfer of medical records is addressed in Section 4.9 of this agreement.
• The Provider may request the disenrollment of an enrollee for good cause as defined by Medicaid program guidelines.
• Beneficiaries may file a complaint and/or grievance according to Medicaid policy.
• If the Division fails to make a disenrollment determination so that the beneficiary can be disenrolled no later than the first day of the second month following the month in which the beneficiary or the Provider files the request, the disenrollment is considered approved.

1. 2. Agreement Violation Provisions

The failure of a Provider to comply with the terms of this agreement may result in the following sanctions by the Division:

1. 1. 1. Limiting member enrollment with the Provider.
      2. Referral to DHB Program Integrity Unit for investigation of potential fraud or quality of care issues.
      3. Referral to North Carolina Medical Board.
      4. Termination of the Provider from the Carolina ACCESS program.

One or more of the above sanctions may be initiated simultaneously at the discretion of the Division based on the severity of the agreement violation. The Division makes the determination to initiate sanctions against the Provider. The Provider will be notified of the initiation of a sanction by certified mail. Sanctions may be initiated immediately if the Division determines that the health or welfare of an enrollee(s) is endangered or within a specified period of time as indicated in the notice. If the Provider disagrees with the sanction determination, it has the right to request an evidentiary hearing as defined by Medicaid policy.

Failure of the Division to impose sanctions for an Agreement violation does not prohibit the Division from exercising its rights to do so for subsequent Agreement violations.

Federal Financial Participation (FFP) is not available for amounts expended for Providers excluded by Medicare, Medicaid, or State Children’s Health Insurance Program (SCHIP), except for emergency services.

1. 3. Application Process

The Provider will complete an application to submit with the signed Agreement for review and approval by the Division.

1. 4. Exceptions to the Agreement

The Division may approve exceptions to this Agreement if, in the opinion of the Division, the benefits of the Provider’s participation outweigh the Provider’s inability to comply with a portion of this agreement.

In order to amend this Agreement, the Provider shall submit a written request to the Division for consideration for exception from a specific Agreement requirement. The request shall include the reasons for the Provider’s inability to comply with this Agreement requirement. The request shall be submitted at the time this Agreement is submitted to the Division for consideration. Approval of the application constitutes acceptance of the request for an exception.

1. 5. Transfer of Agreement

This Agreement may not be transferred.

1. 6. Agreement Termination

This Agreement may be terminated by either party, or by mutual consent, upon at least thirty (30) days written notice delivered by certified mail with return receipt requested and will be effective only on the first day of the month, pursuant to processing deadlines.

The Division under the following conditions may terminate this Agreement immediately:

• In the event that State or federal funds that have been allocated to the Division are eliminated or reduced to such an extent that, in the sole determination of the Division, continuation of the obligations at the levels stated herein may not be maintained. The obligations of each party shall be terminated to the extent specified in the notice of termination immediately upon receipt of notice of termination from the Division; or
• If the Provider (a) is determined to be in violation of terms of this Agreement, or applicable federal and State laws, regulations, and policy, and/or (b) fails to maintain program certification or licensure; or
• Upon the death of the Provider, the sale of the Provider’s practice, or termination of participation as a Medicaid or Medicare provider; or
• In the event of conduct by the Provider justifying termination, including but not limited to breach of confidentiality or any other covenant in this Agreement, and/or failure to perform designated services for any reason other than illness.

The Provider must supply all information necessary for reimbursement of outstanding Medicaid claims.

7. Effective Date and Duration

This Agreement shall become effective on                                                     (to be completed by DHB office staff) and remain in effect until amended or terminated pursuant to the terms of this Agreement.