Massachusetts Behavioral Health


AFDC

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Recipient - shall mean any individual in one of the following Categories of Assistance who is not an Excluded Recipient: ...
   (02) AFDC (Aid to Families with Dependent Children)…"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 14.

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Recipient - shall mean any individual in one of the following Categories of Assistance who is not an Excluded Recipient: …
   (06)MA/AFDC (Medical Assistance/Aid to Families with Dependent Children and Commonwealth) …"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 14.

Poor children

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Recipient - shall mean any individual in one of the following Categories of Assistance who is not an Excluded Recipient: …
   (8) MA/Under 18 (Medical Assistance for Recipients under 18 years of age)…"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 14.

Persons with disability

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Recipient - shall mean any individual in one of the following Categories of Assistance who is not an Excluded Recipient: …
  (03) SSI/Disabled (Supplemental Security Income for Disabled Recipients)...
  (07) MA/disabled (Medical Assistance for Disabled Recipients)...
  (14) Massachusetts Commission for the Blind…"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 14.

Refugees

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Recipient - shall mean any individual in one of the following Categories of Assistance who is not an Excluded Recipient: …
  (00) Refugee Program…"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 14.

Other individuals

"A. DEFINITIONS...
The following definitions shall be amended or added: ...

3. 'Excluded Recipient' shall be amended by deleting the definition in its entirety and replacing it with the following:
'Excluded Recipient' shall mean any individual who is excluded from participate in the Division's managed care options pursuant to Division regulations at 130 CMR 501et seq."  Massachusetts MH/SAP Contract, Amendment 2, pages 1-2.

Enrollee selection of plan

"SECTION 4:  DIVISION  RESPONSIBILITIES...
4.4.  Enrollment and Disenrollment for Recipients
A.  Enrollment and Eligibility Verification

The Division shall:
1.  maintain sole responsibility for the enrollment of Recipients into the MH/SAP;
2.  notify the Contractor of all enrollments; and
3.  enable the Contractor to verify each Recipients eligibility status in the MH/SAP through access to the Recipient Eligibility Verification System (REVS) or through nightly transfer of REVS file updates, or both."  Massachusetts MH/SAP Contract, Appendix A, page 35.

Persons in ongoing treatment

"B. Clinical Transition Plan
During the Phase-In Period, the Contractor shall: ...
11. Notwithstanding any other provision of this Contract, the Contractor shall be required to do the following, beginning in June 1996: ...
  b. For Diversionary Service cases previously authorized by MHMA, inc. prior to July 1, 1996 for services to be continued after July 1, 1996, honor and continue to authorize such services up until, but not after, September 30, 1996, unless the Contractor determines that continuation of such services meets Clinical Necessity Criteria contained in Appendix E to this Contract;

  c.  For Outpatient Service cases previously authorized by MHMA, Inc. prior to July 1, 1996 for services to be continued after July 1, 1996, honor and continue to authorize such service up until, but not after, September 30, 1996 or not to exceed the 12 automatically authorized sessions, whichever, comes first, unless the Contractor determines that continuation of such services meets the Clinically Necessary Criteria contained in Appendix E to this Contract..."  Massachusetts MH/SAP Contract, Appendix A, pages 26-28.

Persons in inpatient settings

"B. Clinical Transition Plan
During the Phase-In Period, the Contractor shall: ...
11. Notwithstanding any other provision of this Contract, the Contractor shall be required to do the following, beginning in June 1996:
  a. For Inpatient services cases previously authorized by MHMA, Inc. prior to July 1, 1996 for services to be continued after July 1, 1996, honor and continue to authorize such services up until, but not after, July 31, 1996 unless the Contractor determines that continuation of such services meets Clinical Necessity Criteria contained in Appendix E to this Contract…"  Massachusetts MH/SAP Contract, Appendix A, pages 26-27

Service coverage, limits, and exclusions

"3.2  Delivery and Coordination of Services
The Contractor shall: ...
D.  inform Enrollees of the availability of all Medically Necessary Covered Services listed in Appendix C to this Contract as well as services at alternative levels of care and the way for Enrollees to access such services…"  Massachusetts MH/SAP Contract, Appendix A, page 21.

"1.03  Communication
The Contractor shall: ...
1.03.03 Create, maintain, and update educational and informational material regarding Covered Services... which shall be submitted to the Division for its prior review and approval prior to distribution of this material to any party including, but not limited to, Enrollees, Providers, Enrollees, family members, and other interested parties."  Massachusetts MH/SAP Contract, Appendix B, pages 3-4.

Participating provider

"1.03 Communication
The Contractor shall: ...
1.03.03 Create, maintain, and update educational and informational material regarding... access to the Provider Network... which shall be submitted to the division for its prior review and approval prior to distribution of this material to any party including, but not limited to, enrollees, Providers, enrollees, family members, and other interested parties."  Massachusetts MH/SAP Contract, Appendix B, pages 3-4.

Other

"1.03 Communication
The Contractor shall: ...
1.03.03 Create, maintain, and update educational and informational material regarding... access to the Provider Network... which shall be submitted to the division for its prior review and approval prior to distribution of this material to any party including, but not limited to, enrollees, Providers, enrollees, family members, and other interested parties."  Massachusetts MH/SAP Contract, Appendix B, pages 3-4.

"3.0 CUSTOMER SERVICES
The contractor shall: ...
3.02 Operate a toll-free Customer Services Department telephone line at a minimum or with hours per day during normal business hours, Monday through Friday, which shall: ...

  f. inform Enrollees of the tool-free telephone number, provide an overview of Covered Services and the role of the Contractor, through multi-lingual brochures placed in local Department of Transitional Assistance offices, the Division's MassHealth regional offices, DMH's area offices, the Division's Health Benefits Management vendor, and through written materials distributed to Network Providers…"  Massachusetts MH/SAP Contract, Appendix B, page 24.

Grievances and complaints procedures

"1.03 Communication
The Contractor shall: ...
1.03.03 Create, maintain, and update educational and informational material regarding... Appeals, complaint, and grievance processes, which shall be submitted to the division for its prior review and approval prior to distribution of this material to any party including, but not limited to, enrollees, Providers, enrollees, family members, and other interested parties."  Massachusetts MH/SAP Contract, Appendix B, pages 3-4.

"7.0  Appeals and Grievances
The Contractor shall:
7.01 Maintain written policies and procedures for the filing, receipt, prompt resolution, and documentation of any and all appeals and grievances of service authorization decisions for covered Services brought by enrollees, enrollees' family members, or Providers on behalf of enrollees.  such policies and procedures shall be approved by the Division, and include, at a minimum, the following: ...
  b.  a mechanism for informing enrollees of the appeals and grievance procedures…" Massachusetts MH/SAP Contract, Appendix B, page 53.

Plan disenrollment for loss of coverage or eligibility

"SECTION 4: DIVISION RESPONSIBILITIES…
4.4  Enrollment and Disenrollment for Recipients...
B.  Disenrollment Processes and Payment Terms

The Division shall:
1.  Administer disenrollments due to loss of eligibility by:
  a.  notifying the Contractor of an Enrollee's disenrollment through access to REVS or through nightly transfer of REVS file updates, or both; and
  b. at its discretion, automatically re-enrolling in the MH/SAP Enrollees who were disenrolled due to a loss of eligibility and whose eligibility has been reestablished."  Massachusetts MH/SAP Contract, Appendix A, pages 29, 35.

Mental health and substance abuse

"3.2.  Delivery and Coordination of Services
The Contractor shall:
A.  be responsible for ensuring the delivery of all the Covered Services listed in Appendix C to this Contract without modification;

B.  arrange, coordinate, and authorize the provision of all Medically Necessary Covered Services listed in Appendix C to this Contract..." Massachusetts MH/SAP Contract, Appendix A, page 21.

Prescription drugs

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
C.  Emergency Services...
  2.  Medication Management Services - shall mean...prescribing of medication by qualified personnel as a component of Emergency Services…"  Massachusetts MH/SAP Contract, Appendix C, pages 1-3.

Case management

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise...

Case Management - shall mean a systematic approach to coordinating an individual's care which is designed to efficiently utilize health care resources to achieve the optimum health care outcome in the most cost-effective manner."  Massachusetts MH/SAP Contract, Appendix A, page 6.

"2.06.07  Agreements with State Agencies
The Contractor shall: ...
b.  Develop and submit to the Division for prior review and approval within the first six months of the Contract, a plan to ensure that its Network Management staff communicate on an ongoing basis, and  no less than monthly, with DSS designated staff, DPH/BSAS designated staff,  DMH area directors and other appropriate state agencies' designated staff  to address Enrollees' service planning, admissions, discharge plans, utilization, and coordination of DMH Continuing Care Services."  Massachusetts MH/SAP Contract, Appendix B, pages 22-23.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c.  Incentives Only...
4) Intensive Case Management/Consumers who are Dually- Diagnosed
The Contractor shall target an increase in enrollment in the Intensive Case Management (ICM) program of at least 100 individuals, at least 75 of whom must be members with a dual- diagnosis (substance abuse and psychiatric) and include both disabled adults and adolescents…"  Massachusetts MH/SAP Contract,  Amendment 1, page 14.

"e.  Initiatives with Administrative Costs Only...
3)  Expanded Intensive Case Management Program
The Contractor shall increase enrollment in the Intensive Case Management (ICM) program by at least 100 individuals..."  Massachusetts MH/SAP Contract, Amendment 1, page 19.

Treatment services for individuals with dual diagnosis

"5.01 Department Structure and Staffing
The Contractor  shall:
5.01.01 Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following: ...
h. specialty services and programs, such as:
  1. Dual Diagnoses…"  Massachusetts MH/SAP Contract, Appendix B, page 29.

"5.07 Dual Diagnosis
The Contractor shall:
5.07.01  Design, develop, and submit to the Division for prior review and approval a list of a continuum of services to meet the needs of Enrollees with a Dual Diagnosis.  The Contractor shall:
a.  ensure that the continuum of care shall include adequate service capacity for the following:
  1.  assessment;
  2.  Emergency and Crisis Stabilization;
  3.  Inpatient Services;
  4.  Freestanding Detoxification;
  5.  Partial Hospitalization or alternative step-down;
  6.  Residential Treatment;
  7 .  Structured Outpatient Addiction Program;
  8.  Day Treatment;
  9.  Outpatient Services; and
 10.  Acupuncture Detoxification...

b.  consult and collaborate with DPH/BSAS in building the continuum of care, developing education programs for clinicians, and developing Credentialing and recredentialing requirements for substance abuse clinicians.

c.  in conjunction with the Division, work with designated central office staff from DMH and DPH/BSAS to encourage the development of appropriate residential programming at a range of intensities and types which meet the needs of enrollees with a Dual diagnosis upon their discharge from inpatient levels of care, and which complement Outpatient Services."  Massachusetts MH/SAP Contract, Appendix B pages 44-45.

"1.  DMA Covered Services
A.  Inpatient Services - shall mean twenty-four hour services which provide medical intervention for mental health or substance abuse diagnoses, or both.

1.  Enhanced Level III Detoxification for Pregnant Women - shall mean short term medical treatment for substance use withdrawal, medical assessment and intervention, including both medical and social components, to ensure quality substance abuse treatment and obstetrical care to pregnant women

2. Inpatient Mental Health Services - shall mean hospital services to stabilize an acute psychiatric condition which: 1) has a relatively sudden onset; 2) has a short, severe course; 3) poses a significant danger to self or other; and/or 4) has resulted in marked psychosocial dysfunction and/or grave mental disability.

3.  Inpatient Substance Abuse Services (Level IV) - shall mean hospital services which provide a planned detoxification regimen of 24 hour medically directed evaluation, care and treatment for psychoactive substance abusing individuals in a medically managed inpatient setting.

4.  Level III Detoxification - shall mean Inpatient Substance Abuse Services that provide short-term medical treatment for substance use withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post- detoxification referrals.  These services may be provided in licensed freestanding or hospital-based programs."  Massachusetts MH/SAP Contract, Appendix C, page 1.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c.  Incentives Only...
4) Intensive Case Management/Consumers who are Dually- Diagnosed
The Contractor shall target an increase in enrollment in the Intensive Case Management (ICM) program of at least 100 individuals, at least 75 of whom must be members with a dual- diagnosis (substance abuse and psychiatric) and include both disabled adults and adolescents.  All dually diagnosed individuals must be newly enrolled in the ICM subsequent to June 30, 1997..."  Massachusetts MH/SAP Contract, Amendment 1, pages 14, 16-17.

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G…
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provision and Standards...
4. Dual diagnosis/Dual Recovery - through the efforts of a statewide coalition of consumers and advocated, including the Massachusetts Clubhouse Coalition, the Contractor shall coordinate and ensure the provision of dual diagnosis (mental illness and substance abuse) recovery education, training and support,  Such education, training and support.  Such education, training and support shall emphasize the Dual Recovery Anonymous model, with the goal of establishing more groups in the Commonwealth,  The compliance target for this standard shall be:

1) demonstration of engagement with a statewide coalition of consumers and advocates to ensure the  provision of dual diagnosis recovery education, training and support; and
2) the convening of a statewide conference on the Dual Recovery Anonymous model."  Massachusetts MH/SAP Contract, Amendment 6, pages 1, 3-4.

Care coordination/case management

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

DMH case management services of Care Management Services - shall mean mental health Case Management conducted by DMH or its agents, and available to DMH continuing Care consumers, including those Recipients who are also DMH continuing Care Consumers.  Core elements of DMH case Management Service functions include assessment, treatment planning, service linkage, monitoring, and client advocacy…"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 8.

"Intensive Clinical Management (ICM) - shall mean the administration and provision of a set of clinical management services delivered to High Demand Cases."  Massachusetts MH/SAP Contract, Appendix A, page 11.

"3.2 Delivery and Coordination of Services
The Contractor shall: ...
J. manage certain inpatient mental health beds for uninsured children that DMH currently manages pursuant to a Memorandum of Understanding between DMH and those private psychiatric hospitals ('Private Psychiatric Hospitals') identified in Appendix Y to this Contract. Management shall include referral and screening of clinically appropriate, uninsured children, utilization review services and discharge planning."  Massachusetts MH/SAP Contract, Appendix A, pages 21-22.

"2.06.07  Agreements with State Agencies
The Contractor shall: ...
  b.  Develop and submit to the Division for prior review and approval within the first six months of the Contract, a plan to ensure that its Network Management staff communicate on an ongoing basis, and  no less than monthly, with DSS designated staff, DPH/BSAS designated staff,  DMH area directors and other appropriate state agencies' designated staff  to address Enrollees' service planning, admissions, discharge plans, utilization, and coordination of DMH Continuing Care Services."  Massachusetts MH/SAP Contract, Appendix B, pages 22-23.

"5.01 Department Structure and Staffing
The Contractor shall:
5.01.01 Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following: ...
  f.  Intensive case management…"  Massachusetts MH/SAP Contract, Appendix B, page 29.

"5.01.04 Design and submit to the Division for prior review and approval, a plan to be implemented within the first month of the Contract, which shall ensure that clinicians in the Utilization Management Department who are coordinating services and making service authorization decisions have training and experience in the specific area of service for which they are coordinating and authorizing services. The Contractor shall ensure the following:

  a. that the clinician coordinating and authorizing adult mental health services shall be a clinician with experience and training in adult mental health services;
  b. that the clinician coordinating and authorizing child and adolescent mental health services shall be a clinician with experience and training in child and adolescent mental health services;
  c. that the clinician coordinating and authorizing adult substance abuse services shall be a clinician with experience and training in adult substance abuse services;
  d. that the clinician coordinating and authorizing child and adolescent substance abuse services shall be a clinician with experience and training in child and adolescent substance abuse services;
  e. that the clinician coordinating and authorizing Dual Diagnosis services shall be a clinician with experience and training in Dual Diagnosis services; and
  f. that the clinician coordinating and authorizing services for an Enrollee with a coexisting medical and mental health or substance diagnosis shall be a Registered Nurse or Psychiatrist with experience and training in services with a coexisting medical and mental health and substance abuse diagnosis…"  Massachusetts MH/SAP Contract, Appendix B, page 32.

"5.05 Intensive Clinical Management
The Contractor shall:
5.05.01 Develop and submit to the Division for prior review and approval a plan to implement an Intensive Clinical Management (ICM) Program with the goal of stabilizing and maintaining the Enrollee in the community, which shall be implemented within the first six months of the Contract...

5.05.02 Assign complex, high utilization, and high risk mental health and substance abuse cases to the ICM Program and to a specific clinician within the ICM Program.

5.05.03 Operate an ICM Program that shall include:
  a. assessment;
  b. treatment planning;
  c. case monitoring;
  d. coordination and authorization of services;
  e. collaboration with the DMH Care Manager, who shall have responsibility for the management of Enrollees who are enrolled in the ICM Program and who shall be receiving DMH Continuing Care Services;
  f. service linkage; and
  g. client advocacy.

5.05.04 Ensure that the ICM services are appropriate to Enrollees' needs, and monitor the appropriateness through its service authorization, utilization review, and clinical audit processes.

5.05.05 Develop and submit to the Division for prior review and approval subcontracts with community support service providers to perform on-site client assessment, treatment planning, service linkage, monitoring, client advocacy and outreach for Enrollees who the ICM Program staff have determined shall benefit from such services...

5.05.06 Amend the ICM Program from time-to-time, subject to Division prior review and approval, provided, however, that the amended ICM Program shall consist of a plan containing, at a minimum, the elements set forth in Section 5.05.01. of Appendix B to this Contract."  Massachusetts MH/SAP Contract, Appendix B, pages 41-43.

"5.11 Substance Abuse Services for Pregnant Women
The Contractor shall:
5.11.01  Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available:
d.  Intensive Clinical Management..." Massachusetts MH/SAP Contract, Appendix B, pages 47-48.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c.  Incentives Only...
  4) Intensive Case Management/Consumers who are Dually- Diagnosed
The Contractor shall target an increase in enrollment in the Intensive Case Management (ICM) program of at least 100 individuals, at least 75 of whom must be members with a dual- diagnosis (substance abuse and psychiatric) and include both disabled adults and adolescents.  All dually diagnosed individuals must be newly enrolled in the ICM subsequent to June 30, 1997...

e.  Initiatives with Administrative Costs Only...
  3)  Expanded Intensive Case Management Program
The Contractor shall increase enrollment in the Intensive Case Management (ICM) program by at least 100 individuals..."  Massachusetts MH/SAP Contract, Amendment 1, pages 14, 19.

Crisis care

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Emergency Screening Services, Emergency Services, and Short Term Crisis Stabilization Services Program (ESP) - shall mean a program to be designed by the Contractor, in the event the Contractor does not utilize, or does not exclusively utilize, the DEPs as permitted pursuant to Appendix B to this Contract, subsection 5.02.01, that shall, at a minimum, provide Emergency Screening Services, Emergency Services, and Short Term Crisis Stabilization Services in accordance with the requirements set forth in Section 5.02 of Appendix B to this Contract, and in Appendix K to this Contract…"  Massachusetts MH/SAP Contract, Appendix A, pages 6, 9-10.

"Short Term Crisis Stabilization Services - shall mean any or all of the following:
1) Crisis Stabilization,
2) Observation/Holding beds,
3) Specializing Services,
4) Medication Management Services, and
5) Short Term Crisis Counseling."  Massachusetts MH/SAP Contract, Appendix A, page 15.

"5.02 Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services
The Contractor shall:

5.02.01 Provide Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services...

5.02.04 Submit a plan for Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services for prior review and approval by the Division, that shall at a minimum ensure that the provision of services is consistent with standards set forth in Appendix K to this Contract and in Section 5.02.02. of Appendix B to this Contract...

5.02.05 The Contractor shall ensure the availability of clinicians in the DEPs or ESPs who have special training and experience in mental health and substance abuse, including but not limited to, the following specialty areas: ...

5.02.07 Ensure that the provision of services in DEPs or ESPs must includes access for DMH area directors to short-term crisis beds for DMH Continuing Care Consumers for up to 48 hour stays."  Massachusetts MH/SAP Contract, Appendix B, pages 33-34.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
B.  Diversionary Services...
  2.  Crisis Stabilization - shall mean services provided as an alternative to hospitalization which provides short-term psychiatric treatment in structured, community based therapeutic environments. Crisis Stabilization provides continuous 24 hour observation and supervision for individuals who do not require the intensive medical treatment of hospital level of care…"  Massachusetts MH/SAP Contract, Appendix C, pages 1-2.

"C. Emergency Services - shall mean Medically Necessary Services which are available seven days per week, 24 hours per day to provide treatment of any individual who is experiencing a mental health or substance abuse problem, or both...

3. Short Term Crisis Counseling - shall mean provision of individual therapy as a component of Emergency Services.

4. Short Term Crisis Stabilization Services - shall mean any or all of the following:
1) Crisis Stabilization;
2) Observation/ Holding Beds;
3) Specializing Services ;
4) Medication Management Services; and
5) Short Term Crisis Counseling."  Massachusetts MH/SAP Contract, Appendix C, page 3.

"II. DMH Covered Services...
B.  Diversionary Services...
1.  Crisis Stabilization - shall mean services provided as an alternative to hospitalization which provides short-term psychiatric treatment in structured, community based therapeutic environments. Crisis Stabilization provides continuous 24 hour observation and supervision for individuals who do not require the intensive medical treatment of hospital level of care...

C.  Emergency Services...
3.  Short Term Crisis Counseling - shall mean provision of individual therapy as a component of Emergency Services.

4.  Short Term Crisis Stabilization Services - shall mean any or all of the following:
1) Crisis Stabilization,
2) Observation/ Holding Beds,
3) Specializing Services, and
4) Medication Management Services, and
5) Short Term Crisis Counseling..."  Massachusetts MH/SAP Contract,  Appendix C, pages 7-8.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c.  Incentives Only...
2) Crisis Intervention Capacity for Children and Adolescents
The Contractor shall
  (i)ensure compliance with the child/adolescent service capacity provisions of the Contractor's subcontracts with Emergency Services Programs and
  (ii) assist ESPs in developing protocol agreements with key Department of Social Services and DMH children's residential providers in their service area..."  Massachusetts MH/SAP Contract, Amendment 1, pages 14, 16.

Family therapy

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
D. Outpatient Services
1.  Mental Health...

b.  Mental Health Clinic Treatment...
2.  Family Therapy - shall mean the treatment of more than one member of a family simultaneously in the same session...

d. Substance Abuse Clinic Counseling...
2. Family Counseling - shall mean rehabilitation counseling of more than one member of a family at the same time in the same session, where the primary, complaint is disruption of the family due to substance abuse."  Massachusetts MH/SAP Contract, Appendix C, pages 4-5.

Individual therapy

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services…

C. Emergency Services - shall mean Medically Necessary Services which are available seven days per week, 24 hours per day to provide treatment of any individual who is experiencing a mental health or substance abuse problem, or both...

3. Short Term Crisis Counseling - shall mean provision of individual therapy as a component of Emergency Services...

5. Specialing Services - shall mean therapeutic services provided to an individual, in a variety of settings, on a one-to-one basis to maintain the individual's safety as a component of Emergency Services.

D. Outpatient Services...
  1.  Mental Health...
  b.  Mental Health Clinic Treatment...
  5.  Individual Therapy - shall mean therapeutic services provided to an individual on a one-to- one basis…

d. Substance Abuse Clinic counseling...

4. Individual Counseling - shall mean rehabilitative counseling provided to an individual whose primary complaint is substance abuse."  Massachusetts MH/SAP Contract, Appendix C, pages 1, 4-6.

"II.  DMH Covered Services...
C.  Emergency Services...
3.  Short Term Crisis Counseling - shall mean provision of individual therapy as a component of Emergency Services...

5.  Specialing Services - shall mean therapeutic services provided to an individual, in a variety of settings, on a one-to-one basis to maintain the individual's safety as a component of Emergency Services."  Massachusetts MH/SAP Contract, Appendix C, pages 7-8.

Group therapy

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.   DMA Covered Services...
D.  Outpatient Services...
  1.  Mental Health...
  b.  Mental Health Clinic Treatment
  3.  Group Therapy - shall mean the application of psychotherapeutic or counseling techniques to a group of persons, most of whom are not related by blood, marriage, or legal guardianship...

d. Substance Abuse Clinic Counseling...
3. Group Counseling - shall mean rehabilitative counseling of a group of individuals, most of whom are not related by blood, marriage, or legal guardianship, having a primary complaint that is associated with substance abuse…"  Massachusetts MH/SAP Contract, Appendix C, pages 4-5.

Hospital detoxification

"5.11 Substance Abuse Services for Pregnant Women
  The Contractor shall:
  5.11.01  Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available:
a.  enhanced detoxification..." Massachusetts MH/SAP Contract, Appendix B, pages 46-47.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services
A.  Inpatient Services...
1.  Enhanced Level III Detoxification for Pregnant Women -
shall mean short term medical treatment for substance use withdrawal, medical assessment and intervention, including both medical and social components, to ensure quality substance abuse treatment and obstetrical care to pregnant women...

3.  Inpatient Substance Abuse Services (Level IV) - shall mean hospital services which provide a planned detoxification regimen of 24 hour medically directed evaluation, care and treatment for psychoactive substance abusing individuals in a medically managed inpatient setting.

4.  Level III Detoxification - shall mean Inpatient Substance Abuse Services that provide short-term medical treatment for substance use withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post- detoxification referrals.  These services may be provided in licensed freestanding or hospital-based programs."  Massachusetts MH/SAP Contract, Appendix C, page 1.

Inpatient services for persons under 21

"5.10 Children and Adolescent Services
The Contractor shall:

5.10.01 Design and implement a plan within six months after the Full Service Start Date to ensure that, at a minimum, the following services for children and adolescents are available:
  a. pre-residential step-down programs between inpatient hospital level of care and 24 hour residential level of care...
  c. Crisis Stabilization on-site at DSS residential programs…"  Massachusetts MH/SAP Contract, Appendix B, page 47.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
B.  Diversionary Services...
  9.  Residential Mental Health Treatment for Children and Adolescents - shall mean services providing a therapeutically planned group living situation delivered on a 24 hour basis for individuals under 18 years of age. This service represents an alternative to hospitalization, most commonly as a step- down from Inpatient Mental Health Services.

  10.  Residential substance Abuse Treatment - shall mean short-term twenty-four hour therapeutically planned treatment and learning situation for adults or adolescents which provides continuity of care after level III Detoxification for individuals engaging in recovery."  Massachusetts MH/SAP Contract, Appendix C, pages 1, 3.

"II. DMH Covered Services
A. Inpatient Services - shall mean twenty-four hour services which provide medical intervention for mental health.
1. Inpatient Mental Health Services - shall mean hospital services to stabilize an acute psychiatric condition which:
  1) has a relatively sudden onset,
  2) a short, severe course,
  3) poses a significant danger to self or other, and/ or
  4) has resulted in marked psychosocial dysfunction and/or grave mental disability."  Massachusetts MH/SAP Contract, Appendix C, page 7.

Long-term residential

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
B. Diversionary Services...
  8.  Residential Stabilization Services - shall mean a highly structured milieu of intensive residential treatment available upon discharge from inpatient settings for children and adolescents requiring a residential placement from the Department of Social Services. Designed to foster coordination with the Department of Social Services and to reduce unplanned hospital readmissions, this service is reimbursable for up to thirty days at which point the Department of Social Services assumes financial responsibility for service provision...

  9.   Residential Mental Health Treatment for Children and Adolescents - shall mean services providing a therapeutically planned group living situation delivered on a 24 hour basis for individuals under 18 years of age. This service represents an alternative to hospitalization, most commonly as a step-down from Inpatient Mental Health Services."  Massachusetts MH/SAP Contract, Appendix C, pages 1, 3.

Medication management

"5.06 Discharge Planning
The Contractor shall: ...
5.06.06 Ensure and monitor that Enrollees requiring medication monitoring will be seen within three days of discharge from an inpatient setting by a clinician, who is duly qualified and licensed to provide a Medication Management follow-up visit.

5.06.07 When it determines it to be clinically necessary or otherwise appropriate, refer and have its Providers refer DMH Continuing Care Consumers who are not Recipients to DMH Medication Management Clinics, as set forth in Appendix R to this Contract…"  Massachusetts MH/SAP Contract, Appendix B, pages 43-44.

"5.10 Children and Adolescent Services
The Contractor shall:
5.10.01 Design and implement a plan within six months after the Full Service Start Date to ensure that, at a minimum, the following services for children and adolescents are available: ...
d. Medication Management by a Network Provider nurse or psychiatrist for children and adolescents on-site at a DSS residential program."  Massachusetts MH/SAP Contract, Appendix B, page 47.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
C. Emergency Services...
  2.  Medication Management Services - shall mean assessment for... medication by qualified personnel as a component of Emergency Services...

D.  Outpatient Services...
  1.  Mental Health...
  c.  Mental Health Clinic Medication
  1.  Medication Visit - shall mean an Enrollee's visit to a  Provider specifically for review, monitoring…of medication by a psychiatrist; nurse according to Appendix B, Section 2.02.05; or administration of prescribed intramuscular medication by qualified personnel...

2.  Substance Abuse...
c. Methadone Maintenance - shall mean the continued administering or dispensing of methadone in conformance with U.S. Food and Drug Administration regulations, in conjunction with the provision of appropriate social and medical services, at relatively stable dosage levels as an oral substitute for heroin or other opiate-like drugs. Methadone maintenance includes both a dosing and a counseling service component...
f.  Substance Abuse Medication Visit - shall mean an individual visit specifically for psychopharmacological evaluation...review, and/or monitoring by qualified personnel…"  Massachusetts MH/SAP Contract, Appendix C, pages 1, 4-5.

"II.  DMH Covered Services...
  C.  Emergency Services...
  2.  Medication Management Services - shall mean assessment for...medication by qualified personnel as a component of Emergency Services."   Massachusetts MH/SAP Contract, Appendix C, pages 7-8.

Non-hospital residential detoxification

"5.11 Substance Abuse Services for Pregnant Women
  The Contractor shall:
  5.11.01  Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available:
a.  enhanced detoxification..." Massachusetts MH/SAP Contract, Appendix B, pages 47-48.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
  4.  Level III Detoxification - shall mean Inpatient Substance Abuse Services that provide short- term medical treatment for substance use withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post-detoxification referrals.  These services may be provided in licensed freestanding or hospital-based programs." Massachusetts MH/SAP Contract, Appendix C, page 1.

"D. Outpatient Services...
2. Substance Abuse...
a. Acupuncture Detoxification - shall mean the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, an electric current, heat to the needles, skin, or both in an attempt to withdraw individuals from dependence on substances."  Massachusetts MH/SAP Contract, Appendix C, pages 4-5.

Outpatient treatment

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Outpatient Services - shall mean mental health and substance abuse services set forth in Appendix C to this Contract, Section I.D, which are provided in an ambulatory care setting, such as a mental health or substance abuse clinic, hospital outpatient department, community mental health center, or Provider's office."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 13.

"5.11 Substance Abuse Services for Pregnant Women
The Contractor shall:
5.11.01  Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available:
b.  Intensive Outpatient Services..." Massachusetts MH/SAP Contract, Appendix B, pages 47-48.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
B.  Diversionary Services...
11.  Structured Outpatient Addiction Programs - shall mean short-term clinically intensive structured day and/or evening substance abuse services. It can service as a step-down service in the continuum of care for those individuals being discharged from Level III Detoxification or can be utilized by individuals whose symptoms indicate a need for structured outpatient treatment beyond the standard outpatient benefit…"  Massachusetts MH/SAP Contract, Appendix C, page 1.

"D.  Outpatient Services - shall mean mental health and substance abuse services provided in an ambulatory care setting, such as a mental health or substance abuse clinic, hospital outpatient department, community health center, or Provider's office.

1. Mental Health
  a. Mental Health Clinic Evaluation...
  b. Mental Health Clinic Treatment...
  c. Mental Health Clinic Medication...
  d. Mental Health Clinic Consultation...

2. Substance Abuse
  a. Acupuncture Detoxification...
  b. Intensive Outpatient Substance Abuse Treatment for Pregnant Women...
  c. Methadone Maintenance...
  d. Substance Abuse Clinic Counseling…"  Massachusetts MH/SAP Contract, Appendix C, pages 4-5.

Partial day treatment programs

"5.11 Substance Abuse Services for Pregnant Women
  The Contractor shall:
  5.11.01  Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available:
c.  Day Treatment..." Massachusetts MH/SAP Contract, Appendix B, pages 47-48.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
B. Diversionary Services...
3.  Partial Hospitalization for Adults, Children, and Adolescents -- shall mean an alternative to Inpatient Mental Health Services which offers short-term day mental health programming available 7 days per week consisting of therapeutically intensive acute treatment within a stable therapeutic milieu and including daily psychiatric management...

7.  Psychiatric Day Treatment - shall mean services which constitute a program of a planned combination of diagnostic, treatment, and rehabilitative services provided to mentally or emotionally disturbed persons who need more active or inclusive treatment than is typically available through a weekly visit to a mental health center, individual Provider's office or hospital outpatient department, but who do not need full-time hospitalization or institutionalization…"  Massachusetts MH/SAP Contract, Amendment C, pages 1-2.

"II.  DMH Covered Services...
B.   Diversionary Services...
  3.  Partial Hospitalization for Adults, Children, and Adolescents -- shall mean an alternative to Inpatient Mental Health Services which offers short-term day mental health programming available 7 days per week consisting of therapeutically intensive acute treatment within a stable therapeutic milieu and including daily psychiatric management."  Massachusetts MH/SAP Contract, Appendix C, page 7.

Prescribed drugs

"APPENDIX C
COVERED SERVICES UNDER MH/SAP
I.  DMA Covered Services...
C.  Emergency Services...
  2.  Medication Management Services - shall mean... prescribing of medication by qualified personnel as a component of Emergency Services…"  Massachusetts MH/SAP Contract, Appendix C, pages 1, 3.

"D.  Outpatient Services...
1.  Mental Health...
c.  Mental Health Clinic Medication
1.  Medication Visit - shall mean an Enrollee's visit to a  Provider specifically for...and prescribing of medication by a psychiatrist; nurse according to Appendix B, Section 2.02.05; or administration of prescribed intramuscular medication by qualified personnel...

2.  Substance Abuse...
f.  Substance Abuse Medication Visit - shall mean an individual visit specifically for sychopharmacological...prescription...by qualified personnel…"  Massachusetts MH/SAP Contract, Appendix C, pages 4-6.

"II.  DMH Covered Services...
C.  Emergency Services...
2. Medication Management Services - shall mean...prescribing of medication by qualified personnel as a component of Emergency Services."  Massachusetts MH/SAP Contract, Appendix C, pages 7-8.

"PSYCHOPHARMACOLOGY
7. Medication Protocol for Enhanced Residential Care program (ERC) Participants - The Contractor shall collaborate with ERC programs and with recognized experts in child/adolescent psychopharmacology to develop a psychopharmacological evaluation/treatment protocol for ERC programs and participants.  The contractor shall monitor ERC program compliance with the established protocol and shall ensure the completion of psychopharmacological treatment plans that reflect use of the protocol.  Further, the Contractor shall provide in-service training to REC milieu and clinical staff on state-of the-art practice with respect to child/adolescent psychopharmacology.  The goal of this initiative is to provide more coordinated medication therapy for this group of children/adolescents…"  Massachusetts MH/SAP Contract, Amendment 6, page 5.

"SUBSTANCE ABUSE SERVICES
13. Payment of LAMM/Methadone Case Rate - The Contractor shall work with the Department of Public Health's Bureau of Substance Abuse Services and the substance abuse provider community to develop and conduct a process to: reimburse providers for Levomentadyl Actate Hydrochloride (LAMM) as an alternative opiate replacement therapy; and develop a case rate pilot for reimbursement of methadone as an opiate replacement therapy…"  Massachusetts MH/SAP Contract, Amendment 6, page 8.

Referrals

"5.0 UTILIZATION MANAGEMENT
5.01 Department Structure and Staffing
The Contractor shall:
5.01.01 Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following:
a. referrals and coordination of services...
g. discharge planning…"  Massachusetts MH/SAP Contract, Appendix B, page 29.

"SECTION 5.6:  Free Care Reimbursement to Former Replacement Units
(a)  For the period from July 1, 1996 through the date the Contractor implements a new inpatient provider network pursuant to the Contract, the Contractor shall maintain an agreement (‘Free Care Agreement') with certain of the Replacement Units (‘Selected RUN') providing for the following:
  i)  The Selected RUN will accept for expedited admission all patient referrals from ESPs regardless of the status of the patient's payer..."  Massachusetts MH/SAP Contract, Amendment 1, page 21.

Screening, assessment and diagnosis

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise...
Discharge Planning - shall mean the evaluation of an Enrollee's mental health or substance abuse service needs, or both, in order to arrange for appropriate care after discharge from one level of care to another level of care…" Massachusetts MH/SAP Contract, Appendix A, pages 6-7.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP…
C.  Emergency Services...
1.  Emergency Screening Services -- shall mean a face- to-face assessment, conducted by appropriate clinical personnel as specified in section 2.20.05 of Appendix B (purchasing specifications), of an individual presenting with an Emergency in a home, residential program, clinic, hospital emergency room, police station, and other settings…"  Massachusetts MH/SAP Contract, Appendix C, pages 1, 3.

"D.  Outpatient Services...
1.  Mental Health
  a.  Mental Health Clinic Evaluation
  1.  Diagnostic Services - shall mean the examination and determination of a patient's psychological, social, economic, educational, and vocational assets and disabilities for the purpose of designing a treatment plan…
d.  Mental Health Clinic Consultation...

2. Mental Health Case Consultation - shall mean a preplanned meeting by a mental health professional concerning an individual who is either:
   a) a client, or
   b) one for whom evaluation and assessment have been requested by another agency or program involved in treatment or management of the individual.

2.  Substance Abuse...
e.  Substance Abuse Diagnostic Evaluation - shall mean a bio psychosocial assessment of an individual's physical, psychological, social, economic, educational, environmental, and vocational assets and disabilities for the purpose of designing a treatment plan…"  Massachusetts MH/SAP Contract, Appendix C, pages 4-6.

"II. DMH Covered Services...
C.  Emergency Services...
  1.  Emergency Screening Services - shall mean a face-to-face assessment, conducted by appropriate clinical personnel as specified in section 2.20.05 of Appendix B (purchasing specifications), of an individual presenting with an Emergency in a home, residential program, clinic, hospital emergency room, police station, and other settings..." Massachusetts MH/SAP Contract,  Appendix C, pages 7-8.

"Psychological, Neuropsychological and Chapter 766 Related Educational Testing - shall mean the use of standardized test instruments when indicated for behavioral or physical health reasons to evaluate aspects of an individual's functioning, including, but not limited to, cognitive processes, organically, emotional conflicts, and type and degree of psychopathology, and also including for Chapter 766 Related Educational Testing those assessments identified at 603 CMR 320.2(b)."  Massachusetts MH/SAP Contract, Amendment 1, page 23.

Short-term residential (includes hospital)

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise..

Inpatient Services - shall mean mental  health or substance abuse services, or both, set forth in Appendix C to this Contract, Section I.A and Section II.A, which are provided in a twenty four hour setting, such as a hospital or freestanding detoxification facility."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 11.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP...
I.   DMA Covered Service…

A. Inpatient Services - shall mean twenty-four hour services which provide medical intervention for mental health or substance abuse diagnoses, or both.
  1. Enhanced Level III Detoxification for Pregnant Women...

  2. Inpatient Mental Health Services - shall mean hospital services to stabilize an acute psychiatric condition which:
   1) has a relatively sudden onset;
   2) has a short, severe course;
   3) poses a significant danger to self or other; and/or 4) has resulted in marked psychosocial dysfunction and/or grave mental disability.

  3. Inpatient Substance Abuse Services (Level IV) - shall mean hospital services which provide a planned detoxification regimen of 24 hour medically directed evaluation, care and treatment for psychoactive substance abusing individuals in a medically managed inpatient setting.

  4. Level III Detoxification - shall mean Inpatient Substance Abuse Services that provide short-term medical treatment for substance use withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post-detoxification referrals...

B.  Diversionary Services...
  2.   Crisis Stabilization - shall mean services provided as an alternative to hospitalization which provides short-term psychiatric treatment in structured, community based therapeutic environments. Crisis Stabilization provides continuous 24 hour observation and supervision for individuals who do not require the intensive medical treatment of hospital level of care...

  8.   Residential Stabilization Services - shall mean a highly structured milieu of intensive residential treatment available upon discharge from inpatient settings for children and adolescents requiring a residential placement from the Department of Social Services. Designed to foster coordination with the Department of Social Services and to reduce unplanned hospital readmissions, this service is reimbursable for up to thirty days at which point the Department of Social Services assumes financial responsibility for service provision...

  9.   Residential Mental Health Treatment for Children and Adolescents - shall mean services providing a therapeutically planned group living situation delivered on a 24 hour basis for individuals under 18 years of age. This service represents an alternative to hospitalization, most commonly as a step- down from Inpatient Mental Health Services...

  10.  Residential Substance Abuse Treatment - shall mean short-term twenty-four hour therapeutically planned treatment and learning situation for adults or adolescents which provides continuity of care after Level III Detoxification for individuals engaging in recovery…"  Massachusetts MH/SAP Contract, Appendix C, pages 1-3.

"II.  DMH Covered Services...
B.   Diversionary Services...
  1.  Crisis Stabilization - shall mean services provided as an alternative to hospitalization which provides short-term psychiatric treatment in structured, community based therapeutic environments. Crisis Stabilization provides continuous 24 hour observation and supervision for individuals who do not require the intensive medical treatment of hospital level of care.

  2.  Observation/Holding Beds - shall mean service to provide hospital level care for up to 24 hours to provide time for assessment, stabilization, and identification of appropriate resources for individuals..."  Massachusetts MH/SAP Contract, Appendix C, pages 7-8.

Transportation

"5.02 Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services
The Contractor shall: ...

5.02.04 Submit a plan for Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services for prior review and approval by the Division, that shall at a minimum ensure that the provision of services is consistent with standards set forth in Appendix K to this Contract and in Section 5.02.02. of Appendix B to this Contract.

In its plan, the Contractor shall describe the following: ...
  c. how it shall ensure the provision of or arrangement for transportation services to an Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services treatment setting when necessary."  Massachusetts MH/SAP Contract, Appendix B, pages 33-34.

Other

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Diversionary Services - shall mean those mental health and substance abuse services which are provided as alternatives to Inpatient Services and which satisfy all access, quality, and cost-effectiveness standards developed by the Contractor and approved by the Division."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 8.

"3.2 Delivery and Coordination of Services
The Contractor shall: ...
C. beginning January 1, 1997, unless otherwise agreed to by the Division, provide clinically appropriate access to services at alternative levels of care for Recipients, including but not limited to self-help/drop-in services for mental health; self-help/drop-in services for substance abuse treatment; transitional support services for substance abuse treatment; and mobile outreach for foster care families."  Massachusetts  MH/SAP Contract, Appendix A, page 21.

"5.01 Department Structure and Staffing
The Contractor shall:
5.01.01 Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following: ...
e. treatment planning...
h. specialty services and programs, such as:

1. Dual Diagnoses;
2. DEP or ESP, whichever is appropriate;
3. homelessness;
4. PCC linkage;
5. peer & self-help groups; and
6. substance abuse programs for pregnant women."  Massachusetts MH/SAP Contract, Appendix B, page 29.

"5.11 Substance Abuse Services for Pregnant Women
The Contractor shall:
5.11.01  Ensure that, at a minimum, the following substance abuse services for pregnant women with a substance abuse diagnosis are available: ...
e.  community support programs...

5.11.02  Design and monitor a plan to maintain open access to the above-listed services as set forth in subsection 5.11.01. of Appendix B to this Contract...

5.11.05  Design and implement an ongoing training program to educate the contractor's clinical staff and Network Providers regarding the specialized service needs of pregnant substance abuse women, which shall at a minimum, include education regarding substances typically used, standard treatment protocols, and other educational materials such as those developed by the coalition on addiction, Pregnancy, and Parenting (CAPP)."  Massachusetts MH/SAP Contract, Appendix B, pages 47-48.

"APPENDIX C
COVERED SERVICES UNDER MH/SAP...
I.   DMA Covered Services
B.  Diversionary Services...
1.  Community Support for Adults, Children, and Adolescents - shall mean services, provided in a community setting, which are used to prevent hospitalization and designed to respond to needs of individuals whose pattern of utilization of services or clinical profile indicates high risk of readmission into 24 hour treatment settings...

4. Family Stabilization - shall mean services which provide short-term flexible services to assist care-givers in stabilizing children and adolescents in home settings. These supportive services are delivered during an episode of acute mental illness or substance abuse or after out-of-home treatment, such as Inpatient Mental Health or Substance Abuse Services, for such an episode. These services are designed to divert services from hospital settings, prevent repeated hospitalizations or to allow children and adolescents to move from the hospital to a less restrictive setting more quickly.

D.  Outpatient Services...
1.  Mental Health
b.  Mental Health Clinic Treatment...
4.  Home Visits - shall mean crisis intervention, individual, group, or family therapy, and medication provided in the enrollee's residence, when unable to be served at the Provider's facility and as clinically appropriate...

E.  Special Procedures
1.  Electro-Convulsive Therapy - shall mean service which initiates seizure activity with an electric impulse while the individual is under anesthesia. It is administered in a hospital facility which is licensed to provide this service by the Department of Mental Health...

II.  DMH Covered Services...
C.  Emergency Services...
5.  Specializing Services - shall mean therapeutic services provided to an individual, in a variety of settings, on a one-to-one basis to maintain the individual's safety as a component of Emergency Services."  Massachusetts MH/SAP Contract,  Appendix C, pages 1-8.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
c.  Incentives Only…"  Massachusetts MH/SAP Contract, Amendment 1, page 14.

"5) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined MassHealth eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager.  For consumers who are eligible for DMH services as of July 1, 1997 (‘Known Consumers'), the Contractor shall target to complete such outreach activities within 90 days of the inception of MassHealth Expansion.  For all new DMH acute care consumers (‘New Consumers'), the Contractor shall target to complete such outreach activities within 45 days of the Contractor's receipt of the consumer's DMH eligibility information...

e.  Initiatives with Administrative Costs Only…
4)  Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager..."  Massachusetts MH/SAP Contract, Amendment 1, pages 16, 19.

Emergency care: Coverage

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise...

Designated Emergency Program (DEP) - shall mean current programs that provide a comprehensive set of Emergency Services designed to assess and treat an individual with a psychiatric crisis or severe emotional disturbance, which is characterized by a serious disruption of the individual's usual level of functioning. DEP services support DMH Continuing Care Services in the community and prevent unnecessary inpatient hospitalization through timely and effective assessment and intervention. DEPs are available to anyone in need regardless of the source of payment for services. The standards for the DEPs are set forth in Appendix K to this Contract. The term 'DEP' shall refer either to the program described in this definition and elsewhere in this Contract, or to the treatment centers providing the services pursuant to such program, depending on the context: …"  Massachusetts MH/SAP Contract, Appendix A, pages 6-7.

"Emergency Screening Services - shall mean a face-to-face assessment, conducted by appropriate clinical personnel as specified in Appendix B to this Contract, Section 5 of an individual presenting with an Emergency in a home, residential program, clinic, hospital emergency room, police station, and other settings.

Emergency Screening Services, Emergency Services, and Short Term Crisis Stabilization Services Program (ESP) - shall mean a program to be designed by the Contractor, in the event the Contractor does not utilize, or does not exclusively utilize, the DEPs as permitted pursuant to Appendix B to this Contract, subsection 5.02.01, shall, at a minimum, provide Emergency Screening Services, Emergency Services, and Short Term Crisis Stabilization Services in accordance with the requirements set forth in Section 5.02 of Appendix B to this Contract, and in Appendix K to this Contract. The term 'ESP' shall refer either to the program described in this definition and elsewhere in this Contract or to the treatment centers providing the services pursuant to such program, depending on the context.

Emergency Services - shall mean Medically Necessary Services which are available seven days per week, 24 hours per day to provide treatment for any individual who is experiencing a mental health Emergency or substance abuse Emergency, or both."   Massachusetts MH/SAP Contract, Appendix A, pages 9-10.

"5.02 Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services
The Contractor shall:

5.02.01 Provide Emergency Screening, Emergency Services...

5.02.04 Submit a plan for Emergency Screening, Emergency Services...for prior review and approval by the Division, that shall at a minimum ensure that the provision of services is consistent with standards set forth in Appendix K to this Contract and in Section 5.02.02 of Appendix B to this Contract...

5.02.05 The Contractor shall ensure the availability of clinicians in the DEPs or ESPs who have special training and experience in mental health and substance abuse, including but not limited to, the following specialty areas: 1) children and adolescents, 2) Dual Diagnosis, 3) Emergency Services, 4) Emergency Screening Services...

5.02.06 Require and ensure that DEPs or ESPs have arrangements, agreements, or procedures to coordinate care with Network Providers, DMH area offices, and all DMH Continuing Care Service providers in each Region...

5.02.08 Report to the Division on service volume for Emergency Screening, Emergency Services and Short Term Crisis Stabilization Services."  Massachusetts MH/SAP Contract, Appendix B, pages 33-34.

"5.03.07  Develop Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services policies and procedures for Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services, to be submitted to the Division for prior review and approval, implement them on the Full Service Start Date, and ensure that these policies and procedures shall, at a minimum, satisfy the following requirements:

  a.  ensure Enrollees unrestricted access to Emergency mental health and substance abuse services, as described in Appendix C to this Contract, on a twenty-four (24) hour basis, seven (7) days a week;
  b.  permit Enrollees access to Emergency Services through direct self-referral; the Contractor's toll-free telephone line; or referral by family members or guardians, Provider, PCC, or community agency. (Presentation at emergency facilities shall constitute self- referral)..."   Massachusetts MH/SAP Contract, Appendix B, page 37.

"5.1.1C.5: PERFORMANCE INCENTIVES AND PENALTIES;  INITIATIVES...
c.  Incentives Only...
2) Crisis Intervention Capacity for Children and Adolescents
The Contractor shall
(i)ensure compliance with the child/adolescent service capacity provisions of the Contractor's subcontracts with Emergency Services Programs and
(ii) assist ESPs in developing protocol agreements with key Department of Social Services and DMH children's residential providers in their service area..."  Massachusetts MH/SAP Contract, Amendment 1, pages 14, 16.

Coverage for urgent and emergency services out-of-plan

"Emergency - shall mean a serious medical condition resulting from injury, sickness, or mental illness which arises suddenly,  manifests itself by symptoms of sufficient severity,  and requires immediate care and treatment to avoid jeopardy to the life or health of the individual or harm to another person by the individual...

Emergency Services - shall mean Medically Necessary Services which are available seven days per week, 24 hours per day to provide treatment for any individual who is experiencing a mental health Emergency or substance abuse Emergency, or both."  Massachusetts MH/SAP Contract, Appendix A, pages 9-10.

"2.05  Provider Reimbursement...
2.05.07  Reimburse non-Network hospital providers as follows, when they provide mental health and/or substance abuse Emergency Services..."  Massachusetts MH/SAP Contract, Appendix B, pages 17-19.

Definition of emergency specific to mental health or substance abuse

"I. DMA Covered Services
A. Inpatient Services - shall mean twenty-four hour services which provide medical intervention for mental health or substance abuse diagnoses, or both...
 
2. Inpatient Mental Health Services - shall mean hospital services to stabilize an acute psychiatric condition which:
   1) has a relatively sudden onset;
   2) has a short, severe course;
   3) poses a significant danger to self or other; and/or
   4) has resulted in marked psychosocial dysfunction and/or grave mental disability."  Massachusetts MH/SAP Contract, Appendix C, page 1.

General coverage rule

"2.  Delivery and Coordination of Services
The Contractor shall: ...
B.  arrange, coordinate, and authorize the provision of all Medically Necessary Covered Services listed in Appendix C to this Contract..."  Massachusetts MH/SAP Contract, Appendix A, page 21.

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…"  Massachusetts MH/SAP Contract, Appendix A, page 6.

"Medical Necessity Criteria - shahi good morning!ll mean minimal criteria used to determine the most clinically appropriate and necessary level of care and intensity of services as set forth in Appendix E to this Contract to ensure the provision of Medically Necessary Services.

Medically Necessary Service - shall mean those mental health and/or substance abuse services which are: 


1) reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the Enrollee that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity, and

2) there is no other equally effective course of treatment available or suitable for the Enrollee requesting the service that is more conservative or substantially less costly.  Medical services shall be of a quality that meets professionally recognized standards of health care, and shall be substantiated by records including evidence of such medical necessity and quality…"  Massachusetts MH/SAP Contract, Appendix A, page 12.

Services in court orders or justice system plans

"5.2  Reimbursement Methodology for DMH Acute Care Consumers
Payment by the Division to the Contractor for DMH Acute Care Consumers shall be as follows,  provided, however, that notwithstanding any other provision of this Contract, DMA shall not be required to make any of the payments for DMH Acute Care Consumers described below unless and until it has received funding from DMH in the amounts necessary to make any and all such payments:

A.  Compensation Rates...
5.  Enrollees ordered hospitalized by a judge pursuant to M.G.L. c. 123 Section 12(e) following clinical evaluation through a court clinic shall be admitted to a hospital pursuant to court order without regard to Medical Necessity.  The Contractor shall require its Providers to provide continued inpatient mental health services if the Contractor determines they are Medically Necessary.  The Contractor shall be responsible for payment of only those services to Enrollees which the Contractor determines are Medically Necessary, as defined in Appendix E to this Contract." Massachusetts MH/SAP Contract, Appendix A, pages 51-53.

Hospitals and other institutions

"SELECTIVE PROVIDER CONTRACTING PROCUREMENT
The Contractor shall maintain and utilize the current MH/SAP provider network and DEP's, until such time as the Contractor has completed the competitive procurement process for each type of service, as set forth below, or as otherwise agreed to by the Division...

The Division shall require the Contractor to select and procure a Provider Network according to the purchasing specifications set forth in Section 2.0 of Appendix B to this Contact entitled 'Provider Network Development, Administration and Management' and the following timetable:

Type of Service...
Acute inpatient mental health services..
Acute inpatient detoxification services...
Designated Emergency Programs…
Residential and Day Treatment…"  Massachusetts MH/SAP Contract, Appendix J.

Mental health and substance abuse providers

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…"  Massachusetts MH/SAP Contract, Appendix A, page 6.

DMH Medication Management Clinic - shall mean the list of clinics as set forth in Appendix R to this Contract."  Massachusetts MH/SAP Contract, Appendix A, page 9.

"5.02  Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services
The Contractor shall: ...

5.02.05 The Contractor shall ensure the availability of clinicians in the DEPs or ESPs who have special training and experience in mental health and substance abuse, including but not limited to, the following specialty areas:
1) children and adolescents,
2) Dual Diagnosis,
3) Emergency Services,
4) Emergency Screening Services,
5) Short Term Crisis Stabilization Services, and
6) geriatrics.

5.02.06 Require and ensure that DEPs or ESPs have arrangements, agreements, or procedures to coordinate care with Network Providers, DMH area offices, and all DMH Continuing Care Service providers in each Region.

5.02.07 Ensure that the provision of services in DEPs or ESPs must includes access for DMH area directors to short-term crisis beds for DMH Continuing Care Consumers for up to 48 hour stays."  Massachusetts MH/SAP Contract, Appendix B, pages 33-34

"SELECTIVE PROVIDER CONTRACTING PROCUREMENT
The Contractor shall maintain and utilize the current MH/SAP provider network and DEP's, until such time as the Contractor has completed the competitive procurement process for each type of service, as set forth below, or as otherwise agreed to by the Division...

The Division shall require the Contractor to select and procure a Provider Network according to the purchasing specifications set forth in Section 2.0 of Appendix B to this Contact entitled 'Provider Network Development, Administration and Management' and the following timetable:

Type of Service...
Acute inpatient mental health services...
Acute inpatient detoxification services...
Designated Emergency Programs (DEP's) or ESP, whichever is applicable...
Residential and Day Treatment...
Outpatient Services...
All other Covered Services..."  Massachusetts MH/SAP Contract, Appendix J.

Primary care providers

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Primary Care Clinician (PCC) - shall mean a Division-contracted primary care provider participating in the managed care program pursuant to 130 CMR 450.118.

Primary Care Clinician Plan (PCCP/PCC Plan) - shall mean the Division program that includes PCCs who provide comprehensive, primary care services and function as the referral source for a Recipient's specialty care."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 12.

Dual diagnosis providers

"5.01.04... The Contractor shall ensure the following: ...
e.  that the clinician coordinating and authorizing Dual Diagnosis services shall be a clinician with experience and training in Dual Diagnosis services; and
f.  that the clinician coordinating and authorizing services for an Enrollee with a coexisting medical and mental health or substance diagnosis shall be a Registered Nurse or Psychiatrist with experience and training in services with a coexisting medical and mental health and substance abuse diagnosis..."  Massachusetts MH/SAP Contract, Appendix B, page 32.

"5.07 Dual Diagnosis
The Contractor shall: ...
5.07.02  Require that Providers who will be authorized to provide services to Enrollees with a Dual Diagnosis have training, experience, and education working with the Dual Diagnosis population."  Massachusetts MH/SAP Contract, Appendix B, pages 44-45.

"15.  Dual Diagnosis Service Capacity
The Contractor shall identify, develop or enhance existing mental health and/or substance abuse inpatient and acute residential treatment capacity for adults and adolescents dually diagnosed with a mental health and a substance abuse disorder.  Identification, development or enhancements of existing inpatient and acute residential treatment capacity shall be based on dual diagnosis program performance specifications to be developed in collaboration with recognized area subject matter experts and key stakeholders…"  Massachusetts MH/SAP Contract, Amendment 4, pages 24-25.

Mental health and substance abuse providers

"3.2 Delivery and Coordination of Services
The Contractor shall: ...
J. manage certain inpatient mental health beds for uninsured children that DMH currently manages pursuant to a Memorandum of Understanding between DMH and those private psychiatric hospitals ('Private Psychiatric Hospitals') identified in Appendix Y to this Contract. Management shall include referral and screening of clinically appropriate, uninsured children, utilization review services and discharge planning. Services provided by the Private Psychiatric Hospitals pursuant to the current MOU, a copy of which is also attached hereto in Appendix Y to this Contract, and any subsequent MOU that DMH may negotiate, shall be provided free of charge to the Contractor, DMH and the Division. The Contractor shall separately report to the Division on inpatient admissions of uninsured children to the Private Psychiatric Hospitals…"  Massachusetts MH/SAP Contract, Appendix A, pages 21-22.

"2.02.09 Require that inpatient hospital Providers develop organizational and clinical linkages with each of the DEPs and/or ESPs, including procedures to credential and grant admitting privileges to DEP and/or ESP psychiatrists and hold regular meetings and conduct ad hoc communication on clinical and administrative issues with the DEPs and/or ESPs."  Massachusetts MH/SAP Contract, Appendix B, page 12.

"5.08  Primary Care Clinician (PCC) Linkage
The Contractor shall:
5.08.01  Submit to the Division for prior review and approval and implement within the first six months of the Contract a plan to facilitate communication and coordination of Recipients' mental health, substance abuse, and medical care between the Provider, PCC, and the Contractor.  The plan shall, at a minimum, include policies and procedures that meet the following requirements: ...

c.  ensure that the Provider communicates and coordinates the Recipient's care with the PCC once written consent has been obtained to release information;
d.  in coordination with the division's PCC Plan staff or their designees, provide education and training for all PCCs to familiarize the PCCs with the use of mental health and substance abuse screening tools, instruments, and procedures to identify mental health and substance abuse problems at the earliest point in time;
e.  provide education to Providers about the PCC Plan.
f.  designate the Contractor's appropriate clinical and non-clinical staff who shall participate in division sponsored PCC training;
g.  require the contractor's medical director or assistant medical director to attend the PCC advisory committee meetings on a regular basis;
h.  identify and designate the Contractor's representative who shall function as a liaison with the PCC Plan;
i.  coordinate its ICM Program with the division's PCC Plan high cost case management program, which shall involve the exchange of information and collaborative placement and discharge Planning coordination for cases with coexisting medical and mental health/substance abuse diagnoses; and
j.  create a policy and procedure to be followed by the contractor and, at the division's discretion, the division's drug utilization review program, to monitor the prescription patterns of the contractor's physicians, and, at the division's discretion, PCC Plan physicians' prescription patterns..."  Massachusetts MH/SAP Contract, Appendix B, pages 45-46.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES INITIATIVES...
c.  Incentives Only
1)  Primary Care Clinician Linkage
The Contractor shall measure the percentage of disabled adult members admissions to inpatient psychiatric facilities where there is evidence of telephonic or written notification by the inpatient facility to the member's Primary Care Clinician, as identified by the member or DMA; provided, however, that such measure shall include only those admissions of disabled adult members who have provided written consent to their treating facility to contact their PCC..."  Massachusetts MH/SAP Contract, Amendment 1, pages 14, 16.

Dual diagnosis providers

"5.01.04... The Contractor shall ensure the following: ...
e.  that the clinician coordinating and authorizing Dual Diagnosis services shall be a clinician with experience and training in Dual Diagnosis services; and
f.  that the clinician coordinating and authorizing services for an Enrollee with a coexisting medical and mental health or substance diagnosis shall be a Registered Nurse or Psychiatrist with experience and training in services with a coexisting medical and mental health and substance abuse diagnosis..."  Massachusetts MH/SAP Contract, Appendix B, page 32.

"5.07 Dual Diagnosis
The Contractor shall: ...

5.07.03  Submit a plan for the Division's prior review and approval for implementation on the Full Service Start Date to identify Enrollees with a Dual Diagnosis prior to their entry to treatment and once they are already in ongoing treatment, and then coordinate and authorize their services with a Provider, as set forth in Section 5.03. of Appendix B to this Contract."  Massachusetts MH/SAP Contract, Appendix B, pages 44-45.

"G. Performance Standards and Initiatives...
15. Dual diagnosis Services Capacity
The Contractor shall identify, develop or enhance existing mental health and/or substance abuse inpatient and acute residential treatment capacity for adults and adolescents dually diagnosed with a mental health and a substance abuse disorder.  Identification, development or enhancements of existing inpatient and acute residential treatment capacity shall be based on dual diagnosis program performance specifications to be..."  Massachusetts MH/SAP Contract, Amendment 4, pages 24-25.

Changes in primary care provider selection/assignment

"4.0 ACCESS AND AVAILABILITY
The Contractor shall: ...
4.01.07 Develop and submit to the Division for prior review and approval, a plan to be implemented within the first four months of the first Contract Year that ensures that Enrollees have the option of changing Providers within the Provider Network."  Massachusetts MH/SAP Contract, Appendix B, pages 27-28.

Mental health

"5.03.07 Develop Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services policies and procedures…
a.  ensure enrollees unrestricted access to Emergency mental health and substance abuse services, as described in appendix C to this Contract, on a twenty-four (24) hour basis, seven (7) days a week;
b. permit Enrollees access to Emergency Services through direct self-referral..."  Massachusetts MH/SAP Contract, Appendix B, page 37.

Substance abuse

"5.03.07 Develop Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services policies and procedures…
a.  ensure enrollees unrestricted access to Emergency mental health and substance abuse services, as described in appendix C to this Contract, on a twenty-four (24) hour basis, seven (7) days a week;
b. permit Enrollees access to Emergency Services through direct self-referral..."  Massachusetts MH/SAP Contract, Appendix B, page 37.

Utilization review process

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Utilization Management - shall mean the process of evaluating the clinical necessity, appropriateness, and efficiency of care and services.  This process may include service authorizations; prospective, concurrent, and retrospective reviews of services and Providers' care; case management - including catastrophic case management; and discharge planning."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 16.

"5.0 UTILIZATION MANAGEMENT
5.01 Department Structure and Staffing
The Contractor shall:
 5.01.01 Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following:
  a. referrals and coordination of services; .
  b. authorization of services;
  c. denial of services;
  d. monitoring and assessment of services and outcomes;
  e. treatment planning;
  f. Intensive case management;
  g. discharge planning;
  h. specialty services and programs...
  i. policy and procedure development for:

1. Medical Necessity Criteria;
2. level of care criteria;
3. service authorization criteria, including:
  a. reauthorization criteria;
  b. continued care/stay criteria; and
  c. discharge criteria…" Massachusetts MH/SAP Contract, Appendix B, page 29.

"5.03  Service Authorization and Utilization Review
The Contractor shall:
5.03.01  Develop policies and procedures to be submitted to the Division for prior review and approval, to be implemented within the first month of the Contract, which shall include, but not be limited to, the following functions:
  a.  service authorization;
  b.  concurrent review;
  c.  Case Management;
  d.  Discharge Planning; and
  e.  retrospective review." Massachusetts MH/SAP Contract, Appendix  B, pages 33-34.

Prior authorization prohibited for certain procedures

"2.05  Provider Reimbursement
The Contractor shall: ...
2.05.05 Develop and implement a claims denial policy and procedure, prior to the Full Service Start Date of the Contract, subject to prior review and approval by the Division, which shall include, at a minimum, the following policies and procedures:
  a.  deny reimbursement for claims for any service which were not authorized by the Contractor, except for clinically appropriate Emergency Services and initial outpatient sessions, which do not require pre-authorization..."  Massachusetts MH/SAP Contract, Appendix B, page 17.

Reviewers clinically competent

"4.0 ACCESS AND AVAILABILITY
The Contractor shall: ...

4.01.03 Maintain a clinical referral line 24 hours a day, seven (7) days a week that is staffed, at a minimum, by clinician who have received a Master's degree in a relevant field."  Massachusetts MH/SAP Contract, Appendix B, page 27.

"5.0  UTILIZATION MANAGEMENT
5.01  Department Structure and Staffing
The Contractor shall: ...

5.01.02  Organize a Utilization Management Department multi- disciplinary clinical team, which shall include, at a minimum, the following staff:
  a. a full-time medical director, at least one full-time assistant medical director, and additional assistant medical directors as needed, all of whom are:
  1.  board certified or board eligible in psychiatry and neurology;
  2. in compliance with all federal, state, and local professional licensing requirements...
  4.  representative of specialty areas, which, at a minimum, include addictionology, child and adolescent psychiatry and adult psychiatry;
  5. have at least two or more years experience in managed behavioral health care or peer review activities, or both...

5.01.04  Design and submit to the Division for prior review and approval, a plan to be implemented within the first month of the Contract, which shall ensure that clinicians in the Utilization Management Department who are coordinating services and making service authorization decisions have training and experience in the specific area of service for which they are coordinating and authorizing services..."  Massachusetts MH/SAP Contract, Appendix B, pages 29-32.

"5.03 Service Authorization and Utilization Review
The Contractor shall: …

5.03.09 Submit to the division for prior review and approval and implement on the Full Service Start Date, service denial policies and procedures which shall include, but not be limited to, the following requirements:
a) ensure that service denials are rendered by board certified or board eligible psychiatrists of the same or similar specialty as the services being denied…"  Massachusetts MH/SAP Contract, Appendix B, pages 34, 38.

Time limits for prior authorization

"3.2 Delivery and Coordination of Services
The Contractor shall: ...
G. require that Providers file prior authorization requests for continuing outpatient services sufficiently in advance of the requested start date for services...

I.  respond in writing to Network and non-Network Providers' requests for outpatient service authorizations within 10 business days of receipt of a verbal, written or electronic request for such service authorization…"  Massachusetts MH/SAP Contract, Appendix A, pages 21-22.

"f.  Performance Standard for Inpatient Prior Approvals: The contractor shall provide a prior approval decision for all DMA Inpatient services and all DMH Inpatient Services within three (3) hours of receiving assessment information from a credentialed clinical Provider, DEP or credentialed ESP, whichever is applicable…

g.  Performance Standard for Continuation of Care:  The Contractor shall provide a prior approval decision within twenty four (24) hours of receiving a request with all necessary clinical information from a Provider for continuation of care beyond the initial pre-approved period, for all Enrollees for the following services:  inpatient psychiatric services, level IV detoxification services, holding beds, crisis stabilization beds, acute residential treatment services, acute partial hospital treatment services, day program services, level III detoxification services, and short-term addiction residential treatment program services..."  Massachusetts MH/SAP Contract, Appendix A, pages 46-47.

"5.03 Service Authorization and Utilization Review
The Contractor shall:
5.03.05 Develop and submit to the Division for prior review and approval Inpatient Services authorization policies and procedures, to be implemented on the Full Services Start Date, which shall at a minimum contain the following requirements: ...
  c. a system to assign an initial length of stay and communicate the physician for all Emergency and non-emergency inpatient admissions verbally within 3 hours and in writing within 24 hours…"  Massachusetts MH/SAP Contract, Appendix B, pages 34-36.

"Continuation of Care/Prior Approval Requirement: The Contractor shall provide a prior approval decision within twenty four (24) Hours of receiving a request with all necessary clinical information from a Provider for continuation of care beyond the initial pre- approved period, for all Enrollees for the following services: inpatient psychiatric services, Level IV detoxification services, holding beds, crisis stabilization beds, acute residential treatment services, acute partial hospital treatment services, day program services, Level III detoxification services, and short-term addiction residential treatment program services." Massachusetts MH/SAP Contract, Amendment 1, page 23.

"I. Section 2.03.01: Network Administration
Section 2.03.01 of Appendix B is modified by adding the following new subsection 2.03.01(a): 'Continuation of Care/Prior Approval Requirement: The Contractor shall provide a prior approval decision within twenty four (24) hours of receiving a request with all necessary clinical information from a Provider for continuation of care beyond the initial pre-approved period, for all Enrollees for the following services: inpatient psychiatric services, Level IV detoxification services, holding beds, crisis stabilization beds, acute residential treatment services, acute partial hospital treatment services, day program services, Level III detoxification services, and short-term addiction residential treatment program services.'"  Massachusetts MH/SAP Contract, Amendment 1, page 23.

24-hour telephone access for prior authorization

"4.0 ACCESS AND AVAILABILITY
The Contractor shall: ...
4.01.03 Maintain a clinical referral line 24 hours a day, seven (7) days a week that is staffed, at a minimum, by clinician who have received a Master's degree in a relevant field."  Massachusetts MH/SAP Contract, Appendix B, page 27.

"5.0  UTILIZATION MANAGEMENT…
5.03  Service Authorization and Utilization Review
The Contractor shall: …

5.03.05  Develop and submit to the Division for prior review and approval Inpatient Service authorization policies and procedures, to be implemented on the Full Service Start Date, which shall at a minimum contain the following requirements:
a.  a 24 hour system to pre-authorize both Emergency and non- emergency inpatient admissions of Enrollees to be admitted to facilities in Massachusetts and out-of-state, utilizing the Medical Necessity Criteria set forth in Appendix E to this Contract as a minimum standard...

5.03.07 Develop Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services policies and procedures for Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services, to be submitted to the Division for prior review and approval, implement them on the Full Service Start Date, and ensure that these policies and procedures shall, at a minimum, satisfy the following requirements: …

b. permit Enrollees access to Emergency Services through... the Contractor's toll-free telephone line..."  Massachusetts MH/SAP Contract, Appendix B, pages 28, 34-37.

Required to use review or authorization for mental health and substance abuse

"3.2 Delivery and Coordination of Services
The Contractor shall: ...
G. require that Providers file prior authorization requests for continuing outpatient services sufficiently in advance of the requested start date for services…"  Massachusetts MH/SAP Contract, Appendix A, pages 21-22.

Required to use review or authorization for dual diagnosis

"5.0  UTILIZATION MANAGEMENT...
  5.01.01  Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following: ...
h.  specialty services and programs, such as:
  1.  Dual Diagnosis..."  Massachusetts MH/SAP Contract, Appendix B, page 28.

"5.07 Dual Diagnosis
  The Contractor shall: ...
  5.07.04  Design, develop, and implement a plan within the first sixth months of the Contract, and submit the plan to the Division for prior review and approval prior to implementation, which shall be used by the Utilization Management staff to facilitate the transfer of an Enrollee's care who has a Dual Diagnosis from one Provider to another Provider, when the Enrollee with a Dual Diagnosis is in ongoing treatment with a Provider who does not have training, experience, or education working with individuals with a Dual Diagnosis."  Massachusetts MH/SAP Contract, Appendix B, pages 44-45.

Multi-lingual providers in network

"2.02  Provider Credentialing
The Contractor shall: ...

2.02.07 Execute Provider Agreements or enter into other arrangements for services only with providers that demonstrate that they: ...
d. are responsive to linguistic...needs of any minority, homeless person, disabled, or other special population in the area in which they provide services, including the capacity to communicate with Enrollees in languages other than English, when necessary…"  Massachusetts MH/SAP Contract, Appendix B, pages 7, 10.

"2.02.08  Maintain and update annually, at a minimum, the following data regarding Providers: ...
i. ...linguistic capabilities..."  Massachusetts MH/SAP Contract, Appendix B, page 12.

"4.0  ACCESS AND AVAILABILITY
The Contractor shall: ...
4.01.09  Maintain and update annually a list of Providers by type of service who are capable of meeting the needs of major linguistic minorities to be available at all times for use by the Contractor's clinical staff, and to be available upon request by Network Providers, Enrollees, DMA, DMH, and other interested parties."  Massachusetts MH/SAP Contract, Appendix B, pages 27-28.

Disability-communication capacity required in network

"2.02 Provider Credentialing
The Contractor shall: …

2.02.07 Execute Provider Agreements or enter into other arrangements for services only with providers that demonstrate that they: ...
d. are responsive to...unique needs of any minority, homeless person, disabled, or other special population in the area in which they provide services, including the capacity to communicate with Enrollees...who are deaf or hearing impaired..."  Massachusetts MH/SAP Contract, Appendix B, pages 7, 10-11.

Materials in other language or in form useful to people with disabilities

"3.0 CUSTOMER SERVICES
The Contractor shall: ...
3.02 Operate a toll-free Customer Services Department telephone line at a minimum of eight hours per day during normal business hours, Monday through Friday, which shall: ...

f.  Inform Enrollees of the toll-free telephone number, provide an overview of Covered Services and the role of the Contractor, through multi-lingual brochures placed in local Department of Transitional Assistance offices, the Division's MassHealth regional offices, DMH's area offices, the Division's Health Benefits Management vendor, and through written materials distributed to Network Providers.  (Materials shall be written in English, Spanish, Portuguese, Creole, Khmer, Vietnamese, Braille, and any other language, as determined appropriate for Enrollees, by the Division.)"  Massachusetts MH/SAP Contract, Appendix B, page 24.

Cultural competence requirement

"3.2 Delivery and Coordination of Services
The Contractor shall:
c.  Beginning January 1, 1997, unless otherwise agreed to by the Division, provide clinically appropriate access to services at alternative levels of care for Recipients, including but not limited to self-help/drop-in services for mental health; self-help/drop-in services for substance abuse treatment; transitional support services for substance abuse treatment…The Contractor shall enter into Provider Agreements for these services in a geographic and culturally appropriate distribution around the state…"  Massachusetts MH/SAP Contract, Appendix A, page 21.

"G. Performance Standards and Initiatives...
16. Network Provider Cultural Competency Plans
The Contractor shall assist at least 12 high volume impatient, outpatient and/or emergency service providers in select natural service areas to develop a cultural competency plan.  To this end, the Contractor will provide technical assistance to these providers, which may include training in areas such as community needs assessment and agency serf assessment for cultural and linguistic competency…"  Massachusetts MH/SAP Contract, Amendment 4, pages 24-25.

"Section 5.1.3.G: Performance Incentives, Penalties, and Initiatives:  Provisions and Standards…
3.  Emergency Service Program (ESP) Training - In collaboration with consumer on family member trainers, the Contractor shall provide a minimum of one training session for ESP staff on the provision of adult and youth consumer-oriented and family-oriented crisis services in three of the Contractor's regions…This training shall include a module addressing culturally competent assessment and intervention strategies..."  Massachusetts MH/SAP Contract, Amendment 6, pages 1, 3.

Emergency care

"5.03 Service Authorization and Utilization Review
The Contractor shall: ...
5.03.07 Develop Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services policies and procedures for Emergency Services, Emergency Screening Services, and Short Term Crisis Stabilization Services, to be submitted to the Division for prior review and approval, implement them on the Full Service Start Date, and ensure that these policies and procedures shall, at a minimum, satisfy the following requirements: …
d.  require that the response time for face-to-face evaluations in Emergency situations does not exceed one hour from notification of the Emergency by telephone from the referring party or from the time of presentation by the Enrollee for Emergency Services…"  Massachusetts MH/SAP Contract, Appendix B, pages 34, 37-38.

Medically necessary/acute care adult visits

"4.0 ACCESS AND AVAILABILITY
The Contractor shall:
4.01.02 Ensure that Enrollees' access to services is consistent with the degree of urgency, as set forth below: ...
  c. non-urgent care - must be provided within ten working days…"  Massachusetts MH/SAP Contract, Appendix B, page 27.

Medically necessary/acute care pediatric visits

"4.0 ACCESS AND AVAILABILITY
The Contractor shall:
4.01.02 Ensure that Enrollees' access to services is consistent with the degree of urgency, as set forth below: ...
  c.  non-urgent care - must be provided within ten working days…"  Massachusetts MH/SAP Contract, Appendix B, page 27.

Services for mental illness

"5.  Performance Incentives and Sanctions...
  b.  Performance Standard for Outpatient Visits:   The Contractor shall ensure that combined discharges from inpatient hospitals, freestanding detoxification facilities, and acute residential treatment facilities ('inpatient facilities') shall be followed by an outpatient visit within three (3) days of discharge, unless transfer is made to another inpatient facility."  Massachusetts MH/SAP Contract, Appendix A, page 44.

Services for substance abuse disorders

"5.  Performance Incentives and Sanctions...
  b.  Performance Standard for Outpatient Visits:   The Contractor shall ensure that combined discharges from inpatient hospitals, freestanding detoxification facilities, and acute residential treatment facilities ('inpatient facilities') shall be followed by an outpatient visit within three (3) days of discharge, unless transfer is made to another inpatient facility."  Massachusetts MH/SAP Contract, Appendix A, page 44.

Urgent care

"4.0  ACCESS AND AVAILABILITY
The Contractor shall: ...
4.01.02  Ensure that Enrollees' access to services is consistent with the degree of urgency, as set forth below:
b.  urgent care - must be provided within 48 hours..."  Massachusetts MH/SAP Contract, Appendix B, page 27.

For specialty or inpatient care providers

"4.0  ACCESS AND AVAILABILITY
The Contractor shall:

4.01.01  Execute Provider Agreements with Providers to ensure that, at a minimum, 90% of Enrollees have access to all Covered Services utilizing the standards set forth below:
  a.  non-Emergency Inpatient Services -  within 60 miles or 45 minutes travel time.
  b.  all other Covered Services   -  within 20 miles or 30 minutes travel time...

4.01.05  Prepare an individualized plan to address access problems when the Contractor is unable to provide an Enrollee access to services with a Provider using the standards set forth in Sections 4.01.01 and 4.01.02 of Appendix B to this Contract, which shall ensure, at a minimum, regardless of whether the Provider is a Network Provider or non-Network provider, that:
  a.  the particular service shall be provided by the most qualified and clinically appropriate provider available; and
  b.   the provider shall be located within the shortest travel time of the Enrollee's home using the standards set forth in subsection 4.01.01. of Appendix B to this Contract."  Massachusetts MH/SAP Contract, Appendix B, page 27.

"5.1.1C.5: PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
d.  Penalties Only...
4)  Child/Adolescent Inpatient Access
Inpatient capacity for children and adolescents shall be available to 85% of members within 45 miles or 60 minutes of their place of residence provided that such a facility exists..." Massachusetts MH/SAP Contract Amendment 1, pages 14, 19.

"APPENDIX B:
1. Section 4.0 shall be amended by adding at the end thereof a new subsection 4.01.11 which shall state as follows:
4.01.11: Assure that Inpatient Services are available to 85% of child and adolescent Members within a radius of 45 miles or 60 minutes of their place of residence, provided that an Inpatient Services facility with the capacity to treat children and adolescents exists within said radius.'"  Massachusetts MH/SAP Contract, Amendment 4, page 31.

Age

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of...age…The contractor agrees to comply with all applicable Federal and State statutes, rules and regulations prohibiting discrimination in employment including but not limited to: …1964; the Age Discrimination in Employment Act of 1967…"  Massachusetts MH/SAP Contract, page 4.

Disability

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of...Physical or mental handicap… The Contractor agrees to comply with all applicable Federal and State statues, rules and regulations prohibiting discrimination in employment including but not limited to: ...
Section 504 of the Rehabilitation Act of 1973…"  Massachusetts MH/SAP Contract, page 4.

Gender

"18.  Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of...sex…"  Massachusetts MH/SAP Contract, page 4.

Race/ethnicity

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of race, color, national origin, ancestry…The Contractor agrees to comply with all applicable Federal and State statues, rules and regulations prohibiting discrimination in employment including but not limited to: Title VII of the Civil Rights Act of 1964…"  Massachusetts MH/SAP Contract, page 4.

Sexual preference

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of…sexual orientation…"  Massachusetts MH/SAP Contract, page 4.

Other

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of...religion…  The Contractor agrees to comply with all applicable Federal and State statues, rules and regulations prohibiting discrimination in employment including but not limited to: … Massachusetts General Laws Chapter 151B, Section 4(1)…and all relevant administrative orders and executive orders, including Executive Order 227 and Executive Order 246…"  Massachusetts MH/SAP Contract, page 4.

Child welfare

"2.06  Network Management...
2.06.07  Agreements with State Agencies
The Contractor shall:
a. Enter into written service agreements with Massachusetts state agencies  to implement mechanisms to address the special mental health and substance abuse needs of Enrollees who receive services from, or are eligible to receive services from these agencies, and to ensure that MH/SAP services are well coordinated and linked with these state agencies, and submit these service agreements to the Division for prior review and approval.  Subject to such review and approval, service agreements with the following agencies shall be executed by the end of the ninth month of the Contract...
2.  Department of Youth Services..."  Massachusetts MH/SAP Contract, Appendix B, pages 19, 22.

Homeless health

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards…

HOMELESSNESS
8. Discharge Planning - The Contractor shall continue to collaborate with the homeless advocacy community to identify strategies and resources to facilitate appropriate discharge dispositions for homeless adults (MassHealth Standard/Disabilities, MassHealth Basic, DMH Consumers).  The Contractor will also educate certain inpatient mental health providers in the Worcester and Springfield areas on the importance of comprehensive discharge planning for members who are homeless upon discharge.  The Contractor shall utilize established tracking mechanisms to monitor performance relative to the identified strategies, and take appropriate network management action with respect to those inpatient mental health providers whose discharge planning performance fails to comply with the Contractor's discharge planning protocol...

9. Internet Technology and Resources for Services to Homeless Members - The Contractor shall collaborate with the homeless advocacy and health care provider community to develop and construct a discrete web site that will contain aftercare planning best practices, including referral information for both behavioral health and physical health resources, specifically for providers of services to homeless members. Such information shall be organized regionally, as well as by type of resource. The compliance targets for this standard shall be the development and construction of a discrete web site, the compilation of information on aftercare planning best practices, including referral information for both behavioral health and physical health resources specifically for providers of services to homeless members, and the availability of the information on the web site…

"BENEFIT ADVOCACY
15. Homeless Shelters and Detoxification Facilities - The Contractor shall work with certain homeless shelters and Network inpatient detoxification facilities on the completion of the Medical Benefit Request in a manner consistent with the process agreed to by the Contractor and the Division.  The Contractor shall reimburse participating shelters and detoxification facilities a $30 per application incentive, and shall receive an amount equal to 15% of each $30 application incentive paid."  Massachusetts MH/SAP Contract, Amendment 6, pages 1, 5- 9.

Special education

"2.06  Network Management...
2.06.07  Agreements with State Agencies
The Contractor shall:
a. Enter into written service agreements with Massachusetts state agencies  to implement mechanisms to address the special mental health and substance abuse needs of Enrollees who receive services from, or are eligible to receive services from these agencies, and to ensure that MH/SAP services are well coordinated and linked with these state agencies, and submit these service agreements to the Division for prior review and approval.  Subject to such review and approval, service agreements with the following agencies shall be executed by the end of the ninth month of the Contract...
4.  Department of Education..."  Massachusetts MH/SAP Contract, Appendix B, pages 19, 22.

State/local public health

"2.06.07  Agreements with State Agencies
The Contractor shall: ...
b.  Develop and submit to the Division for prior review and approval within the first six months of the Contract, a plan to ensure that its Network Management staff communicate on an ongoing basis, and  no less than monthly, with DSS designated staff, DPH/BSAS designated staff,  DMH area directors and other appropriate state agencies' designated staff  to address Enrollees' service planning, admissions, discharge plans, utilization, and coordination of DMH Continuing Care Services."  Massachusetts MH/SAP Contract, Appendix B, page 22.

State/local mental health

"2.0     PROVIDER NETWORK DEVELOPMENT, ADMINISTRATION, AND MANAGEMENT
2.01  Network Development
The Contractor shall: ...
2.01.08 Agree to enter into non-financial affiliation agreements for the first and second Contract Years with qualified DMH designated state-operated community mental health centers (SOCMHCs) for the provision of Inpatient Mental Health Services and mental health Emergency Services to Enrollees, provided that the SOCMHCs meet the quality and performance standards established for Network Providers.

2.01.09  By no later than the first day of the third Contract Year, the Contractor shall enter into Provider Agreements with SOCMHCs for the provision of Inpatient Mental Health Services and mental health Emergency Services, subject to prior review and approval by the Division, and provided that the SOCMHCs meet the credentialing, quality, and performance standards established for Network Providers.  If Provider Agreements are not executed with the SOCHMCs, then non-affiliation agreements shall remain in effect until the Division directs otherwise." Massachusetts MH/SAP Contract, Appendix B, pages 5-7.

"2.06.07 Agreements with State Agencies
The Contractor shall:
a. Enter into written service agreements with Massachusetts state agencies to implement mechanisms to address the special mental health and substance abuse needs of Enrollees who receive services from, or are eligible to receive services from these agencies, and to ensure that MH/SAP services are well coordinated and linked with these state agencies, and submit these service agreements to the Division for prior review and approval. Subject to such review and approval, service agreements with the following agencies shall be executed by the end of the ninth month of the Contract…

3. Department of Mental Retardation…
b.  Develop and submit to the Division for prior review and approval within the first six months of the Contract, a plan to ensure that its Network Management staff communicate on an ongoing basis, and  no less than monthly, with DSS designated staff, DPH/BSAS designated staff,  DMH area directors and other appropriate state agencies' designated staff  to address Enrollees' service planning, admissions, discharge plans, utilization, and coordination of DMH Continuing Care Services."  Massachusetts MH/SAP Contract, Appendix B, pages 22-23.

State/local substance abuse

"2.06  Network Management...
2.06.07  Agreements with State Agencies
The Contractor shall:
  a. Enter into written service agreements with Massachusetts state agencies  to implement mechanisms to address the special mental health and substance abuse needs of Enrollees who receive services from, or are eligible to receive services from these agencies, and to ensure that MH/SAP services are well coordinated and linked with these state agencies, and submit these service agreements to the Division for prior review and approval.  Subject to such review and approval, service agreements with the following agencies shall be executed by the end of the ninth month of the Contract...
6.  Department of Public Health's Bureau of Substance Abuse...

b.  Develop and submit to the Division for prior review and approval within the first six months of the Contract, a plan to ensure that its Network Management staff communicate on an ongoing basis, and  no less than monthly, with DSS designated staff, DPH/BSAS designated staff,  DMH area directors and other appropriate state agencies' designated staff  to address Enrollees' service planning, admissions, discharge plans, utilization, and coordination of DMH Continuing Care Services..."  Massachusetts MH/SAP Contract, Appendix B, pages 19, 22.

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G: Performance Incentive, Penalties, and Initiatives: Provisions and Standards…

CHILDREN'S SERVICES
10. Enhanced Residential Care (ERC) - The Contractor shall work in collaboration with the Departments of Social Services and Mental Health to implement the ERC pilot program. The goal of this program is to enhance the milieu and clinical capacity of a minimum of five selected residential providers in order to reduce the number of children and adolescents in acute care settings awaiting discharge, for whom there is no available placement...

11. Community - Cased Assessment for Certain Children and Adolescents in the Northeast - The Contractor shall, in collaboration with a workgroup of Department of Mental Health, Department of Social Services, Division and biological/foster family member representatives, develop a comprehensive community-based assessment protocol.  The protocol shall use a strength-based approach to assessment and shall be developed utilizing established assessment tools for children and adolescents,  The Contractor shall field test the assessment protocol for certain identified youth, with one or more providers in the Contractor's Northeast Region.  The compliance targets for this standard shall be:
  1) development of a comprehensive community-based assessment protocol, including the establishment of a rate for the assessment and standards for the credentialing of providers to reform the assessment; and
  2) field testing of the protocol with one or more providers…"  Massachusetts MH/SAP Contract, Amendment 6, pages 1 and 6-7.

"BENEFIT ADVOCACY
15. Homeless Shelters and Detoxification Facilities - The Contractor shall work with certain homeless shelters and Network inpatient detoxification facilities on the completion of the Medical Benefit Request in a manner consistent with the process agreed to by the Contractor and the Division.  The contractor shall reimburse participating shelters and detoxification facilities an $30 per application incentive, and shall receive an amount equal to 15% of each $30 application incentive paid."  Massachusetts MH/SAP Contract, Amendment 6, page  9.

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

PSYCHOPHARMACOLOGY
7. Medication Protocol for Enhanced Residential Care Program (ERC) Participants - The Contractor shall collaborate with ERC programs and with recognized experts in child/adolescent psychopharmacology to develop a psychopharmacological evaluation/treatment protocol for ERC programs and participants.  The Contractor shall monitor ERC program compliance with the established protocol and shall ensure the completion of psychopharmacological treatment plans that reflect use of the protocol.  Further, the Contractor shall provide in-service training to ERC milieu and clinical staff on state-of the-art practice with respect to child/adolescent psychopharmacology.  The foal of this initiative is to provide more coordinated medication therapy for this group of children/adolescents...

SUBSTANCE ABUSE SERVICES
13. Payment of LAMM/Methadone Case Rate - The Contractor shall work with the Department of Public Health's Bureau of Substance Abuse Services and the substance abuse provider Community to develop and conduct a process to: reimburse providers for Levemethadyl Acetate Hydrochloride (LAMM) as an alternative opiate replacement therapy; and develop a case rate pilot for reimbursement of methadone as an opiate replacement therapy…"  Massachusetts MH/SAP Contract, Amendment 6, pages 1, 5-8.

State senior services

"2.06  Network Management...
2.06.07  Agreements with State Agencies
The Contractor shall:
a. Enter into written service agreements with Massachusetts state agencies to implement mechanisms to address the special mental health and substance abuse needs of Enrollees who receive services from, or are eligible to receive services from these agencies, and to ensure that MH/SAP services are well coordinated and linked with these state agencies, and submit these service agreements to the Division for prior review and approval.  Subject to such review and approval, service agreements with the following agencies shall be executed by the end of the ninth month of the Contract...
6.  Executive Office of Elder Affairs."  Massachusetts MH/SAP Contract, Appendix B, pages 19, 22.

Internal QA system

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise...

Total Quality Management (TQM) or Continuous Quality Improvement (CQI) - shall mean a management philosophy, advocated by J.M. Juran, W.E. Deming, and Crosby, among others, which incorporates the following concepts:
  • measuring, understanding, and addressing customer needs as the basis for all organizational efforts;
  • continuous measurement of organizational process, employing statistical measurement tools such as process flow charts, histograms, and run charts; and
  • driving fear out of the organization by identifying processes as the cause of defects, and not individuals, and by focusing efforts upon improving such processes."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 15-16.

"3.3 Quality Improvement Goals
The Contractor shall:
A. submit for the Division's prior review and approval no later than August 15, 1996, Quality Improvement Goals which shall be implemented during the first Contract Year upon receipt of the Division's approval of the Quality Improvement Goals;

B. identify and propose annual Quality Improvement Goals for the Division's prior review and approval no later than six weeks prior to the end of each Contract Year, which shall include measures and timeframes for demonstrating that such Quality Improvement Goals are met;

C. implement the annual Quality Improvement Goals and measures within the first fifteen days of each new Contract Year unless otherwise directed by the Division;

D. participate in workgroups with the Division to develop strategies to ensure that the annual  Quality Improvement Goals are met;

E. participate in semi-annual meetings with the Division, for the primary purpose of reviewing progress toward the achievement of the annual Quality Improvement Goals...

F. meet with the Division at the time and place requested by the Division, if the Division determines that the Contractor is not in compliance with the requirements of the annual Quality Improvement Goals. Upon request by the Division, the Contractor shall be further required to prepare and submit within fourteen days of receiving any such request a corrective action plan to the Division for its prior review and approval."  Massachusetts MH/SAP Contract, Appendix A, pages 22-23.

"6.0 QUALITY MANAGEMENT
6.01 Organizational Structure and Philosophy
The Contractor shall:

6.01.01 Develop a Quality Management Department that shall be operational on the Full Service Start Date...

6.01.03 Create and submit to the Division for prior review and approval an organizational Quality Management plan, which includes, but is not limited  to, the following elements:

  a. a quality philosophy/mission statement;
  b.  a senior manager designated as director of Quality Management with direct responsibility for the development and maintenance of the organizational Quality Management plan;
can organizational quality council charged to oversee the training and implementation of TQM throughout the organization, and to provide leadership in the strategic quality planning process, including the setting of clinical and non-clinical Quality Improvement Goals;
  d. TQM training for all staff in the MH/SAP;
  e. facilitator training for key designated staff in each department of the MH/SAP;
  f. a process for the design, development, and implementation of quality improvement teams, who shall be familiar with the PDCA (Plan, Do, Check, Act) model developed by Dr. Walter Shewart;
  g. a plan for implementation of statistical process control techniques, in both clinical and administrative management, which shall be included in the Contractor's annual Quality Management plan;
  h. a medical record review process for monitoring Network Provider compliance with written policies and procedures, program specifications, and appropriateness of care;
  i. a process to survey Network Providers and Enrollees, at least annually, regarding their satisfaction with the Contractor's  administration of the MH/SAP;
  j. a process to measure reviewer consistency in applying Medical Necessity Criteria in Utilization Management activities...

  1. the format and frequency of reports to be prepared that document results and findings from specific quality improvement projects, management interventions, or measurement efforts related to quality;
  m. inclusion of Enrollees and their families in Quality Management activities; and
  n. a plan for continuing the quality improvement initiatives in process under the Division's previous MH/SAP contract with MHMA, Inc...

6.01.05 Ensure the existence of a Quality Management plan in each Network Provider's organization, and promote structures and processes which facilitate Quality Improvement in the Provider Network.

6.01.06 At DMH's request, participate in DMH quality management activities, which shall include, but not be limited to, monthly attendance by a Contractor's Network Management staff member or designee at DMH area quality council monthly meetings, and participation on DMH quality improvement teams."  Massachusetts MH/SAP Contract, Appendix B, pages 49-50.

"IV.  PROMOTING AND PROTECTING HUMAN RIGHTS...
B.  Integration with quality management.
The systems used to protect the human rights of consumers shall be integrated into the quality assessment and improvement structure of the program. This is intended to ensure that concerns or problems identified through the human rights system are known to and addressed as part of total quality management, and is not intended to limit the roles and responsibilities of the human rights system as described below."  Massachusetts MH/SAP Contract, Appendix I, page 3.

External review of plan's performance

"4.1 Administration
The Division shall: ...
A… The Division representative shall be responsible for: ...
  5. ensuring that the Contractor has adequate staff with expertise in the following areas: administration, operations, finance, management information systems, claims processing and payment, mental health and substance abuse clinical service provision, Quality Management, Utilization Management, Network Management, and Benefit Coordination...

B. Convene three councils, whose members shall be appointed by the Division...
These councils shall be as follows:
  1. an MH/SAP Professional Advisory Council which shall meet every two months, at a minimum, to discuss, review and address issues relating to the implementation, operation, and performance of the MWSAP and Contractor. The MWSAP Professional Advisory Council shall include professionals in the field of mental health and substance abuse, community advocates and representatives from state agencies, and shall report its findings and recommendations in writing to the Division's MH/SAP Director or his or her appointee.

  2. a Consumer Advisory Council which shall meet monthly with the Division and the Contractor, and shall include Enrollees, consumer advocates, and representatives from state agencies. The Consumer Advisory Council shall assess and render its feedback in writing to the Division's MH/SAP Director or his or her appointee regarding the Contractor's ability to provide timely access to high-quality, clinically appropriate mental health and substance abuse services and shall also address relevant topics of interest and concerns of Enrollees, including but not limited to, patients' informed consent, collaborative treatment planning, and medication.

  3. a Family Advisory Council which shall meet every two months, or more frequently if appropriate; and shall include Division and Contractor representatives, Enrollees, family members and guardians, family advocates and associations, and representatives from state agencies.  The Family Advisory Council shall report to the Division's MWSAP and shall address issues associated with policy and program development of the MH/SAP, evaluate problems encountered by Enrollees and suggest resolutions, assess capacity and access to services under the MH/SAP; and present its recommendations in writing to the Division's MWSAP Director or his or her appointee…"  Massachusetts MH/SAP Contract, Appendix A, pages 29-30.

"4.3 Performance Evaluation
The Division shall, at its discretion:

B. meet with the Contractor at a minimum of twice a year to assess the performance of its annual Quality Improvement Goals, as set forth in Section 3.3 of Appendix A to this Contract;

C. review reports submitted by the Contractor;

D. request additional reports that the Division deems necessary for purposes of monitoring and evaluating the performance of the Contractor under the Contract;

E. perform periodic programmatic and financial reviews of the Contractor's performance of  responsibility… The audits may, at a minimum, include a review of the following: ...
  6. Recipient access;
  7. clinical protocols;
  8. individual medical records;
  9. Quality Management program;
  10. appeals, complaints, and grievance procedures; and
  11. patient and Provider satisfaction...

G. inform the Contractor of the results of any performance evaluations conducted by the Division;

H. inform the Contractor of any dissatisfaction with the Contractor's performance and, at its discretion include requirements for corrective action; and

I. conduct Enrollee and Provider satisfaction surveys."  Massachusetts MH/SAP Contract, Appendix A, pages 33-34.

Profiling provider performance

"2.06  Network Management
The Contractor shall: ...

2.06.03  Design and submit to the Division for its prior review and approval, prior to the tenth month of the first Contract Year, a plan to manage the Provider Network, which shall include, but not be limited to, a clearly defined strategy for managing through the Provider Network the issues of access, quality and cost-effectiveness, and shall also include, at a minimum, the following:
  a.  a system for Provider profiling and bench marking..."  Massachusetts MH/SAP Contract, Appendix B, page 19.

"6.02  Appropriateness of Care
The Contractor shall:
6.02.01 Design and maintain mechanisms for monitoring and evaluating variation in Network Provider practice patterns for all service categories, and submit these mechanisms to the Division for prior review and approval."  Massachusetts MH/SAP Contract, Appendix B, page 51.

Evaluation of grievances and complaints

"7.0 APPEALS AND GRIEVANCES
The Contractor shall: ...
7.03 Review the appeals and grievance policies and procedures at least annually, for the purpose of making amendments to improve the policies and procedures."  Massachusetts MH/SAP Contract, Appendix B, page 53.

Corrective action plan

"SECTION REIMBURSEMENT...
  (4)  Subsequent to the Division's review and approval of the corrective action plan and the timetable for its implementation, the Contractor shall implement the corrective action plan within fourteen calendar days."  Massachusetts MH/SAP Contract, page 36.

"2.06  Network Management
The Contractor shall: ...
2.06.04  Develop and submit at the beginning of each Contract Year to the Division for its prior review and approval, a plan identifying the Network Management Department's Provider improvement goals, corrective action plan(s) for the year, and methods to be employed to monitor corrective action plan(s), implementation and progress."  Massachusetts MH/SAP Contract, Appendix B, pages 19, 20.

"5.03  Service Authorization and Utilization Review
The Contractor shall:
5.03.09 Submit to the Division for prior review and approval and implement on the Full Service Start Date, service denial policies and procedures which shall include, but not be limited to, the following requirements:
b. design and implement corrective action plans for Providers, who receive more that a 10% denial rate for prospective, concurrent, or retrospective service authorization requests, including referral of these Providers to the Network Management staff for education and technical assistance."  Massachusetts MH/SAP Contract, Appendix B, pages 34, 38-39.

Linkage between performance measures and service duties

"SECTION 5:  REIMBURSEMENT...
C.  Risk Sharing...
5.  Performance Incentives and Sanctions
  a.  General Provisions
  (1)  All provisions for performance incentives and sanctions described under this section shall also constitute independent requirements under this Contract in addition to operating as standards for the purpose of determining whether the Contractor has earned an incentive or may be subject to sanctions.

  (2)  If the Contractor fails to meet the following performance standards, the Division shall provide written notification to the Contractor.

  (3)  Within 15 business days of the date of the Division's notification of failure to meet a performance standard, the Contractor shall submit a corrective action plan and a timetable for implementation of the corrective action plan to the Division for its review and approval, and any modifications thereto.

  (4)  Subsequent to the Division's review and approval of the corrective action plan and the timetable for its implementation, the Contractor shall implement the corrective action plan within fourteen calendar days.

  (5)  The Division shall have the sole authority for determining whether the Contractor has met, exceeded or fallen below any and all of the requirements set forth in this subsection.

  (6)  The Division shall notify the Contractor when performance has returned to acceptable levels.

  (7)  Failure to meet the performance standards listed in this section may result in imposition of sanctions and penalties listed in Section 5 of Appendix A to this Contract.

  (8)  The Division shall make its determination as to whether the Contractor has complied with the performance standards listed below on a Contract Year basis, to be completed no later than three (3)  months after the end of the first Contract Year, except as otherwise provided in subsection j. herein; and provided, however, that if the Division has not received sufficient material information from the Contractor to make such a determination, it shall not be required to comply with this section...

  (13)  In determining Contractor compliance and achievement against the performance standards  listed below, performance measurements will not be rounded.  For example, if the Contractor is required to achieve a performance level of 105%, the target will not have been achieved if the Contractor's performance is 104.99%.

  (14)  Except as otherwise expressly stated, for any performance standard for which compliance is determined by reference to a baseline, the baseline will be established by the Division, in its sole discretion, utilizing relevant MHMA, Inc. data for calendar year 1995.

  (15)  For the first Contract Year, for purposes of imposing sanctions and/or paying incentives in accordance with the provisions of Sections 5.1.C.5.b.-j. of Appendix A of the Contract, the Division shall measure the Contractor's performance only for the period November 1, 1996 through June 30, 1997.

b.  Performance Standard for Outpatient Visits: The Contractor shall ensure that combined discharges from inpatient hospitals, freestanding detoxification facilities, and acute residential treatment facilities (‘inpatient facilities') shall be followed by an outpatient visit within three (3) days of discharge, unless transfer is made to another inpatient facility...

  (1)  If the annual compliance rate for timeliness of outpatient visits is less than 105% of the baseline but greater than or equal to 100%, the Division may elect to impose a penalty of up to $100,000.

  (2)  If the annual compliance rate for timeliness of outpatient visits is less than 95% but not greater than 100% of the baseline, the Division may elect to impose a penalty of up to $200,000.

  (3)  If the annual compliance rate for timeliness of outpatient visits is equal to or greater than 105% of the baseline, the Division shall pay the Contractor $333,333.

c.  Performance Standard for Readmissions: The Contractor shall ensure that the combined inpatient readmission rate to inpatient hospitals, freestanding detoxification  facilities and acute residential treatment facilities (‘inpatient facilities') within seven (7) days of discharge from any one of the three settings, shall not exceed 5% during the first Contract Year...  Cases where the discharge was against medical advice shall be removed from the sample.

  (1)  If the combined inpatient readmission rate exceeds 5% but is less than or equal to 10%, the Division may elect to impose a penalty of up to $100,000.

  (2)  If the combined inpatient readmission rate is greater than 10%, the Division may elect to impose a penalty of up to $200,000.

  (3)  If the combined inpatient readmission rate equals or is less than 5%, the Division shall pay the Contractor $333,333...

g.  Performance Standard for Continuation of Care: The Contractor shall provide a prior approval decision within twenty four (24) hours of receiving a request with all necessary clinical information from a Provider for continuation of care beyond the initial pre-approved period, for all Enrollees for the following services: inpatient psychiatric services, Level IV detoxification services, holding beds, crisis stabilization beds, acute residential treatment services, acute partial hospital treatment services, day program services, Level III detoxification services, and short-term addiction residential treatment program services...

  (1)  If the annual compliance rate for the continuation of care authorization decision and notification process is less than 95% and greater than 90%, the Division may elect to impose a penalty of up to $100,000.

  (2)  If the annual compliance rate for the continuation of care authorization decision and notification process is 90% or less, the Division may elect to impose a penalty of up to $200,000.

  (3)  If the annual compliance rate for the continuation of care authorization decision and notification process is equal to 95% or more, the Division shall pay the Contractor $333,333...

i.  Performance Standard for Claims Processing: The Contractor shall review, process, and remit a check for Clean Claims submitted to the Contractor by the Provider within thirty days of receipt of the Clean Claims...

  (1)  If the annual compliance rate for claims processing is less than 95% and more than 90%, the Division may elect to impose a penalty of up to $100,000.

  (2)  If the annual compliance rate for claims processing   is 90% or less, the Division may elect to impose a penalty of up to $200,000.

  (3)  If the annual compliance rate for claims processing is equal to or greater than 95%, the Division will pay the Contractor $333,333.

j.  Performance Standard for Report Submission: The Contractor shall submit the reports required pursuant to Section 5 of Appendix A and Section 8 of Appendix B to this Contract in the format and timeframes specified therein with the exception of quarterly and annual reports requiring analysis which will be due within 45 days of the end of the quarter...

  (1)  If the Division determines that the Contractor is one (1) to seven (7) days late in submitting  any such report, the Division may elect to impose a penalty of up to $5,000.

  (2)  Thereafter, the Division may elect to impose a penalty of up to $500 for each additional business day after the seventh day following the report's due date until the date on which the report is delivered to the Division.

  (3)  If the annual compliance rate for report submission meets or exceeds the Division's specifications for report submission, the Division will pay the Contractor $333,333.

6.  Performance Improvement Bonuses
a.  General Provisions

  (1)  The Division shall make its determination as to whether the Contractor has complied with the performance improvement standards listed below on a Contract Year basis, to be completed no later than three (3) months after the end of the first Contract Year, except as otherwise provided in subsection j. herein; and provided, however, that if the Division has not received sufficient  information from the Contractor to make such a determination, it shall not be required to comply with this section.

  (2)  If the Contractor meets or exceeds each of the performance improvement standards listed in subsections 5.1.C.6.b and 5.1.C.6.c, as determined by the Division, the Division shall pay the Contractor a $500,000 performance improvement bonus for each performance improvement.

  (3)  The Division shall have the sole authority for determining whether the Contractor has met, exceeded or fallen below any and all of the requirements set forth in this subsection.

b.  Continuing Care Rate Performance Improvement Standard
The percentage of Enrollees discharged from an inpatient hospital unit who, subsequent to discharge, attend a minimum of one outpatient appointment per month for four months, shall be required to increase 10%...

c.  Discharge Information Performance Improvement Standard
The percentage of inpatient hospital charts with evidence of completed discharge information at the time of discharge shall be required to increase by 7.5%..."  Massachusetts MH/SAP Contract, Appendix A, pages 36, 42-50.

"2.06 Network Management
The Contractor shall: ...

2.06.03 Design and submit to the Division for its prior review and approval, prior to the tenth month of the first Contract Year, a plan to manage the Provider Network, which shall include, but not be limited to, a clearly defined strategy for managing through the Provider Network the issues of access, quality and cost-effectiveness, and shall also include, at a minimum, the following: ...
  b. a system for the Contractor and Provider to identify and establish improvement goals and periodic measurements to track the Provider's progress or lack of progress towards the improvement goals;
  c. a list of improvement goals and measures by Provider type; a reporting schedule; regularly scheduled management meetings by Provider type and by Region; and a mechanism to establish, prioritize, set and measure achievement of Provider improvement goals…"  Massachusetts MH/SAP Contract, Appendix B, page 19.

"6.04  Service Outcomes
The Contractor shall: ...

6.04.03 Use outcome measures based on behavioral health care industry standards after receiving prior review and approval from the Division; or develop outcome measures in collaboration with the Division and Network Providers that are specific to each type of service and ensure that such outcome measures include, at a minimum:
  a. recidivism;
  b. adverse occurrences;
  c. treatment drop-out;
  d. length of time between admissions; and
  e. treatment goals achieved."  Massachusetts MH/SAP Contract, Appendix B, pages 51-52.

"D.  SECTION 5:  REIMBURSEMENT...
6.  Section 5.1.C.5. Of Appendix A shall be amended by deleting subsections d, e, f, and h and replacing them, respectively, with the following subsections:

d.  Performance Standard for Timeliness of Inpatient Admissions:  The Contractor shall ensure that inpatient hospital disposition occur within two hours of receiving clinical assessment information from a credentialed Provider or ESP...
  1)  If the annual compliance rate for timeliness of inpatient admissions is less than 90% and greater than or equal to 80%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate for timeliness of inpatient admissions is less than 80% but greater than 70%, the Division may elect to impose a penalty of up to $200,000.
  3)  If the annual compliance [sic] for timeliness of inpatient admissions is equal to or greater than 90%, the Division shall pay the contractor $333,333.

e.  Performance Standard for Referrals to DMH: The Contractor shall issue corrective action plans to up to 22 inpatient hospital providers with less than a 95% rate of Continuing Care Eligibility (CCE) determination by DMH and/or endorsement by the Contractor...
  1)  If the annual compliance rate exceeds 95% but is not 100%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate is 90% but less than 95%, the Division may elect to impose a penalty of  up to $200,000.
  3)  If the annual compliance rate for issuing corrective action plans is equal to 100%, the Division shall pay the Contractor $333,333.

f.  Performance Standard for Inpatient Prior Approval:  The Contractor shall provide a prior approval decision for all DMA Inpatient Services within one and a half hours of receiving clinical assessment information from a credentialed ESP or Provider...
  1)  If the annual compliance rate for the inpatient prior approvals is less than 90%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate for inpatient prior approval is 85% or less, the Division may elect to impose a penalty of up to $200,000.
  3)  If the annual compliance rate for inpatient prior approvals is greater than or equal to 90%, the Division shall pay the Contractor $333,333 ...

h.  Performance Standards for Prior Approval of Outpatient Services: The Contractor shall provide notification of prior approval and continued care approval decisions for Outpatient Services within ten business days of receiving a verbal or written request, or both complete with all necessary clinical information from the Provider...
  1)  If the annual compliance rate for prior approval and continued care approval decisions and notification for outpatient services is less than 95% and more than 90%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate for the prior approval and continued care approval decisions and notification for outpatient services is less than 90%, the Division may elect to impose a penalty of up to $200,000.
  3)  If the annual compliance rate for prior approval and continued care approval decisions and notification for outpatient services is greater than or equal to 95%, the Division shall pay the Contractor $333,333."  Massachusetts MH/SAP Contract, Amendment 1, pages 5-7.

"5.1.IC.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES
a. General Provisions...
Unless otherwise cited below, all Performance Standards and Initiatives shall be measured for the period August 1, 1997 through June 30, 1998.
b.  Incentive and Penalties

1) Aftercare Planning: Disabled Adults
The Contractor shall measure the percentage of charts for disabled adults discharged from an inpatient psychiatric hospital with evidence of completed aftercare planning...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
  b)  If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $400,000.

2) Family Member/Guardian Involvement: Children and Adolescents
The Contractor shall measure the percentage of charts for children and adolescents discharged from an inpatient psychiatric hospital or mental health acute residential treatment program with documentation of family member/guardian participation or invitation to participate in meetings on the inpatient unit...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
  b)  If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $400,000.

3) Continuing Care: Children and Adolescents
The Contractor shall measure the percentage of children and adolescents discharged from inpatient psychiatric treatment participating in aftercare appointments...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
  b)  If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $450,000.

4) Continuing Care: Adults
The Contractor shall measure the percentage of adults discharged from inpatient psychiatric treatment who receive outpatient treatment within three (3) business days of discharge...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $300,000.
  b)  If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $400,000.

5) Continuing Care: Medication Monitoring
The Contractor shall measure the percentage of members across all rating and age categories discharged from inpatient psychiatric treatment who attend within 21 days of discharge: an outpatient medication evaluation; a medication monitoring appointment; an initial evaluation by a physician or Clinical Nurse Specialist; or a medication group appointment...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $500,000.
  b)  If the actual measure is greater than or equal to the compliance target but less than a 25% increase above the first contract year performance level, the Contractor shall receive a bonus of $500,000; or
  c)  If the actual measure is greater than or equal to a 25% increase above the first contract year performance level, the Contractor shall receive a bonus of $700,000.

6) Readmission Rates: Disabled Adults
The Contractor shall measure the percentage of disabled adult members discharged from inpatient psychiatric treatment who are readmitted within 30 days of discharge...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
  b)  If the actual measure is greater than or equal to the compliance target, the Contractor shall receive a bonus of $400,000.

7) Continuity of Care in Readmission for Children and Adolescents
The Contractor shall measure the percentage of medically necessary readmissions occurring within one year of the initial admission (excluding situations where family choice and bed availability otherwise prevail) for children and adolescents readmitted to the same inpatient mental health treatment facility that was the site of the prior admission...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $300,000.
  b)  If the actual measure is greater than or equal to the compliance target and less than 90% of readmissions, the Contractor shall receive a bonus of $200,000; or
  c)  If the actual measure is greater than or equal to 90% of readmissions, the Contractor shall receive a bonus of $400,000.

c.  Incentives Only
1)  Primary Care Clinician Linkage
The Contractor shall measure the percentage of disabled adult members admissions to inpatient psychiatric facilities where there is evidence of telephonic or written notification by the inpatient facility to the member's Primary Care Clinician, as identified by the member or DMA; provided, however, that such measure shall include only those admissions of disabled adult members who have provided written consent to their treating facility to contact their PCC...This measure shall apply for the period September 1, 1997 through June 30, 1998.
  a)  If the actual measure is greater than or equal to 25% but less than 30% of all admissions described above, the Contractor shall receive a bonus of $150,000; or
  b)  If the actual measure is greater than or equal to 30% but less than 35% of all admissions described above, the Contractor shall receive a bonus of $250,000; or
  c) If the actual measure is greater than or equal to 35% but less than 40% of all admissions described above, the Contractor shall receive a bonus of $400,000; or
  d) If the actual measure is 40% of all admissions described above or greater, the Contractor shall receive a bonus of $600,000.

2) Crisis Intervention Capacity for Children and Adolescents
The Contractor shall
 (i)ensure compliance with the child/adolescent service capacity provisions of the Contractor's subcontracts with Emergency Services Programs and
 (ii) assist ESPs in developing protocol agreements with key Department of Social Services and DMH children's residential providers in their service area
  a)  If 70% of ESP providers document compliance with the ESP subcontract provisions, the Contractor shall receive a bonus of $200,000; or
  b) If 80% of ESP providers document compliance with the ESP subcontract provisions, the Contractor shall receive a bonus of $300,000; or
  c) If 90% of ESP providers document compliance with the ESP subcontract provisions, the Contractor shall receive a bonus of $400,000; and/or
  d) If every contracted ESP executes a protocol agreement with at least two key residential providers in the ESP's service area, the Contractor shall receive a bonus of $200,000.

3) Member Involvement in Aftercare Planning
The Contractor shall measure the percentage of disabled adults discharged from a psychiatric inpatient unit who participate in the development of their discharge/aftercare plans, as evidenced by the documentation of the member's  (a) attendance at discharge planning meetings or
(b) refusal to participate...This measure shall apply for the period October 1, 1997 through June 30, 1998.
  a)  If the actual measure is greater than or equal to the compliance target and less than 25% over the first quarter FY98 baseline, the Contractor shall receive a bonus of $150,000; or
  b)  If the actual measure is greater than or equal to 25% over the first quarter FY98 baseline, the Contractor shall receive a bonus of $350,000.

4) Intensive Case Management/Consumers who are Dually- Diagnosed
The Contractor shall target an increase in enrollment in the Intensive Case Management (ICM) program of at least 100 individuals, at least 75 of whom must be members with a dual-diagnosis (substance abuse and psychiatric) and include both disabled adults and adolescents.  All dually diagnosed individuals must be newly enrolled in the ICM subsequent to June 30, 1997.  If additional ICM days for dually-diagnosed members are greater than or equal to 13,687 by June 30, 1998, the Contractor shall receive a bonus of $400,000.

5) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined MassHealth eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager.  For consumers who are eligible for DMH services as of July 1, 1997 (‘Known Consumers'), the Contractor shall target to complete such outreach activities within 90 days of the inception of MassHealth Expansion.  For all new DMH acute care consumers (‘New Consumers'), the Contractor shall target to complete such outreach activities within 45 days of the Contractor's receipt of the consumer's DMH eligibility information.
  a)  If within the time period described above, the Contractor completes the outreach activities described above for 90% or more of ‘New Consumers', the Contractor shall receive a bonus of $200,000; and/or
  b)  If within the time period described above, the Contractor completes the outreach activities described above for 95% or more of ‘Known Consumers', the Contractor shall receive a bonus of $450,000.

6) Expanded MassHealth Benefit Advocacy: Emergency Services Programs
The Contractor shall receive an amount equal to 15% of the per application incentive which shall be provided to Emergency Services Program providers for completion of the MassHealth Benefit Request.

7) Substance Abuse Capacity
In conjunction with the Department of Public Health's Bureau of Substance Abuse Services, the Contractor shall provide a minimum of two in-service training sessions on substance abuse identification and intervention in each of the three Partnership regions (Western, Central, Eastern)... If 80% or more of ESP clinical staff attend both training sessions by June 30, 1998, the Contractor shall receive a bonus of $400,000.

8) Cultural Competency
The Contractor shall provide a minimum of two in-service training sessions for network providers on cultural and linguistic competency in behavioral health treatment covering network providers in each of the six Partnership subregions.  There shall be discrete workshops at these training sessions which shall address specifically the needs of at least the four largest minority groups served by the Contractor.  If the Contractor provides ten or more training sessions by June 30, 1998, the Contractor shall receive a bonus of $400,000.

9) Administrative Efficiency
For the final nine months of the second contract year, the Contractor intends to have 85% or more of all initial provider claims which are adjudicated, submitted to the Contractor electronically via diskette, modem, or magnetic tape.  If 85% or more of provider claims are submitted as described, the Contractor shall receive a bonus of $350,000.
d.  Penalties Only

1)  Network Procurement
Procurement or recontracting of the provider network (including outpatient, Emergency Services Program, and inpatient providers) shall be completed, as measured by written notification of status mailed to all provider applicants by September 26, 1997.  If letters are not mailed to all applicants by September 26, 1997, the Division may impose a penalty of up to $300,000.

2) Timely and Adequate Reporting
All required reports shall be delivered to the Division within forty- eight (48) hours of the scheduled date/time.  All requests for new reports and revisions to existing reports shall be delivered at the agreed upon schedule.  If the Contractor falls to comply with this standard, the Division may impose a penalty of up to $5,000 per failure up to a maximum of $300,000.

3) Provider Quality Forums
The Contractor shall convene two statewide provider Quality Improvement Forums, one by December 31, 1997 and the other by June 30, 1998 in a central Massachusetts location.  The Contractor shall convene a Quality Management Workshop for providers to be held in each of two different areas of the state by June 30, 1998.  If the Contractor fails to comply with any component of this requirement, the Division may impose a penalty of up to $300,000.

4) Child/Adolescent Inpatient Access
Inpatient capacity for children and adolescents shall be available to 85% of members within 45 miles or 60 minutes of their place of residence provided that such a facility exists.  If the Contractor fails to comply with this requirement, the Division may impose a penalty of up to $300,000.

e.  Initiatives with Administrative Costs Only

1)  Flexible Financing
By April 30, 1998, at least one case rate program or one capitation contract for one provider type or level of care shall be developed and implemented.  If at least one case rate program or one capitation rate contract is implemented by April 30, 1998, the Division shall reimburse the Contractor for actual incremental administrative costs up to $225,000.

2) Automated Eligibility Process: Phase II
By June 30, 1998, the Contractor shall through MHS, add PCP information, demographic and TPL changes received from DMA, test the merge process and through automation, recycle the reject file.  If the systems specifications are reviewed and approved by DMA and the merge process is tested, the Division will reimburse the Contractor for actual incremental administrative costs up to $124,500.

3) Expanded Intensive Case Management Program
The Contractor shall increase enrollment in the Intensive Case Management (ICM) program by at least 100 individuals.  If additional ICM enrollee days total at least 18,250 by June 30, 1998, the Contractor shall receive reimbursement of actual incremental administrative costs up to a maximum of $210,000.

4) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager.  If outreach activities occur for at least 70% of ‘Known Consumers', the Contractor shall receive funding of actual incremental administrative costs up to $122,000.

5) Administrative Efficiency
For the last nine months of the second contract year, if at least 78% of all initial provider claims adjudicated are submitted electronically via diskette, modem, or magnetic tape the Contractor shall receive reimbursement of actual incremental administrative costs up to $25,000."  Massachusetts MH/SAP Contract, Amendment 1, pages 14-20.

"APPENDIX A: ...
2. Section 5.1.1.C.5.b.4, entitled 'Continuing Care: Adults,' shall be amended by deleting the introductory paragraph in its entirety and inserting in lieu thereof the following:
'The Contractor shall measure the percentage of adults discharged from inpatient psychiatric treatment who receive subsequent outpatient treatment as follows: The Contractor will measure the percentage of adults discharged from inpatient psychiatric treatment who either (A) attend an outpatient aftercare appointment within three business days of their inpatient discharge or (B) receive a Bridge Consultation, as defined below, during the course of the inpatient admission, and receive an outpatient aftercare appointment with their Primary Outpatient Provider, as defined below, within 5 business days of the date of such discharge. The compliance target for such measure shall be to increase the percentage of such discharges by at least 15 percentage above the first Contract Year performance level.'"  Massachusetts MH/SAP Contract, Amendment 3, page 1.

"Section 5 of Appendix A of the contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

A.  STANDARDS WITH AN INCENTIVE AND A PENALTY REHABILITATION, RECOVERY, AND EMPOWERMENT...

SERVICE/SYSTEM INTEGRATION
5.  Medication Monitoring - The Contractor shall measure the percentage of adult mental health inpatient discharge events followed by a medication appointment within 14 business days of discharge. The initial compliance target for this standard will be 78% of adult mental health discharge events between July 1, 1999 and March 31, 2000...

6.  Seven Day Aftercare - The Contractor shall increase the percentage of members discharged from inpatient mental health treatment who receive aftercare within seven calendar days. The initial compliance target for this standard shall be a rate greater than 80% for such discharges between July 1, 1999 and March 31, 2000...

PSYCHOPHARMACOLOGY
7.Medication Protocol for Enhanced Residential Care Program (ERC) Participants - The Contractor shall collaborate with ERC programs and with recognized experts in child/adolescent psychopharmacology to develop a psychopharmacological evaluation/treatment protocol for ERC programs and participants.  The Contractor shall monitor ERC program compliance with the established protocol and shall ensure the completion of psychopharmacological treatment plans that reflect use of the protocol… The goal of this initiative is to provide more coordinated medication therapy for this group of children/adolescents...

HOMELESSNESS
8.Discharge Planning - The Contractor shall continue to collaborate with the homeless advocacy community to identify strategies and resources to facilitate appropriate discharge dispositions for homeless adults… The Contractor shall utilize established tracking mechanisms to monitor performance relative to the identified strategies, and take appropriate network management action with respect to those inpatient mental health providers whose discharge planning performance fails to comply with the contractor's discharge planning protocol.  The compliance target for this standard...

9. Internet Technology and Resources for Services to Homeless Members - The Contractor shall collaborate with the homeless advocacy and health care provider community to develop and construct a discrete web site that will contain aftercare planning best practices, including referral information for both behavioral health and physical health resources, specifically for providers of services to homeless members. Such information shall be organized regionally, as well as by type of resource. The compliance targets for this standard shall be the development and construction of a discrete web site, the compilation of information on aftercare planning best practices, including referral information for both behavioral health and physical health resources specifically for providers of services to homeless members, and the availability of the information on the web site...

CHILDREN'S SERVICES
10.  Enhanced Residential Care (ERC)-The Contractor shall work in collaboration with the Departments of Social Services and Mental Health to implement the ERC pilot program. The goal of this program is to enhance the milieu and clinical capacity of a minimum of five selected residential providers in order to reduce the number of children and adolescents in acute care settings awaiting discharge, for whom there is no available placement.  The compliance targets for this standard shall be...

11.Community-Based Assessment for Certain Children and Adolescents in the Northeast - The Contractor shall, in collaboration with a workgroup of Department of Mental Health, Department of Social Services, Division and biological/foster family member representatives, develop a comprehensive community-based assessment protocol.  The protocol shall use a strength-based approach to assessment and shall be developed utilizing established assessment tools for children and adolescents…

The compliance targets for this standard shall be:
1) development of a comprehensive community-based assessment protocol, including the establishment of a rate for the assessment and standards for the credentialing of providers to perform the assessment; and
2) field testing of the protocol with one or more providers...

FAMILIES
12.Preventive Services-Family Support - The Contract shall implement an educational and support model curriculum for MassHealth families. Including families whose primary language spoken at home is Spanish, of children who are receiving or have received mental health services through the Contractor and may be at-risk for a decrease in level of functioning…  The compliance target shall be the provision of an educational and support model to 100 families, a certain percentage of whose primary language spoken at home is Spanish, including a minimum of 65 non-foster families...

SUBSTANCE ABUSE SERVICES
13. Payment of LAMM/Methadone Case Rate - The Contractor shall work with the Department of Public Health's Bureau of Substance Abuse Services and the substance abuse provider community to develop and conduct a process to: reimburse providers for Levomethadyl Acetate Hydrochloride (LAMM) as an alternative opiate replacement therapy… The compliance targets for this standard shall be…"  Massachusetts MH/SAP Contract, Amendment 6, pages 2-8.

Access data

"5.02 Emergency Screening, Emergency Services, and Short Term Crisis Stabilization Services
The Contractor shall: ...

5.02.08  Report to the Division on service volume for Emergency Screening, Emergency Services and Short Term Crisis Stabilization Services."  Massachusetts MH/SAP Contract, Appendix B, pages 33-34.

"8.0  Reporting
The Contractor shall submit for Division prior proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.04  Quarterly Reporting
The Contractor shall deliver quarterly reports regarding the information set forth below, to the Division no later than the 20th day of the month following the end of the quarter.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this contract...

D.  Provider Performance
The contractor shall report on the following performance of Network Providers for access...

H.  Network Providers and Non-Network Providers
The Contractor shall provide an all-inclusive list of its Providers and any other subcontracted non-Network provider, including the effective dates of the Providers' and the non-Network providers' contracts with the Contractor...

8.06 Annual Reporting
The Contractor shall provide annual reports to the division, no later than the 20th day following the end of the annual reporting period established by the division.  failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

The Contractor shall: ...
d.  submit a list of Providers by type of service, discipline, Region, as well as areas of expertise..."  Massachusetts MH/SAP Contract, Appendix B, pages 54, 57-61.

Complaints and grievances

"Data and Reporting Requirements
1.  On-line Data Requirements
For the Division:  The Contractor shall be required to provide designated Division staff with on-line access at all times to the Contractor's  database files which shall include, but not be limited to, access to the following files: ... complaint, appeal, and grievance files..."  Massachusetts MH/SAP Contract, Appendix A, page 20.

"6.0  QUALITY MANAGEMENT...
6.04  Service Outcomes...
6.04.05  Design and maintain a system to track and report in writing to the Division the frequency and severity of Enrollee complaints, appeals, and grievances stratified by Region, Provider, and service type."  Massachusetts MH/SAP Contract, Appendix B,  pages 48-51.

"8.0 REPORTING
The Contractor shall submit for division prior proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis to the division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

A  Complaints, Grievances and Appeals
The Contractor shall report on complaints, grievances and appeals filed by Enrollees (or on behalf of an Enrollee by another party, including providers) and by providers.  The Contractor shall report on the type and nature of each complaint, grievance and appeal.  The Contractor shall provide tracking log reports for grievances and appeals, including resolution and outcome.

8.04  Quarterly Reporting
The Contractor shall deliver quarterly reports regarding the information set forth below, to the division no later than the 20th day of the month following the end of the quarter.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

B.  Complaints, Appeals and Grievances
The Contractor shall report:
1.  the number, nature, and type of Enrollee complaints, appeals, and grievances stratified by Region and type of service;
2.  the number, nature, and type of Provider complaints, appeals, and grievances stratified by Region and type of service;
3.  the resolution and time frame of resolution of complaints, appeals, and grievance for each of the categories listed above; and
4.  the number and percentage of service diversions and service authorization denials which are appealed to the Contractor and the Division's BOH respectively."  Massachusetts MH/SAP Contract, Appendix B pages 54-57.

Financial data

"5.6  Financial Reporting
The Contractor shall:
A.  Notify the Division of any liabilities of the Contractor, its general partners, or their corporate parents which may have a material effect on the financial condition of the Contractor.
B.  Provide on a monthly basis by date of service any payment expenditure data, including, but not limited to claims paid, and  IBNR for Recipients by Category of Assistance for each service, region and Provider, and for DMH Acute Care Consumers for each service, region and Provider...
F.  Provide to the Division on an annual basis a report summarizing indirect administrative expenses charged to the Division as part of this Contract and provide supporting documents to justify the Contractor's calculations to the Division's satisfaction.
G.   For each  Contract Year, provide to the Division copies of annual audited financial statements for the Contractor and its parent corporation within thirty (30) days of their publication.
H.   For each quarter of the Contract Year, provide to the Division an unaudited balance sheet and profit and loss statement for the Contractor and its parent corporation through the most recent quarter of the current Contract Year."  Massachusetts MH/SAP Contract, Appendix A, pages 76-77.

"6.  Additional Financial Requirements
a.  Prior to the Full Service Start Date, and, subsequently on request by the Division, Contractor shall be required to submit documentation about the Contractor's financial condition, including but not limited to:
(1)  an audited financial statement of the organization's financial condition for the two most recent fiscal years..."  Massachusetts MH/SAP Contract, Appendix A, page 82.

"8.0 REPORTING
The Contractor shall submit for division prior proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis to the division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

A.  Claims Processing
The Contractor shall report: ...
3.  Actual expenditures for direct services stratified by type of service and Provider.
4.  Expenditure and utilization data by date of service for enrollees, stratified by type of service, Region, DMH Acute Care Consumers, and Recipient Rating Category...

8.06  Annual Reporting
The Contractor shall provide annual reports to the division, no later than the 20th day following the end of the annual reporting period established by the division.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract.

The Contractor shall:
a.  submit reports that summarize the administrative expenses incurred by the Contractor for the MH/SAP for each calendar year.  Such reports shall account separately for expenses allocated to Recipients and DMH Acute Care Consumers according to a Division-approved allocation methodology...

 c. report the dollar amounts of airy payments made in advance to Providers for claims that have been submitted to the Contractor by the Provider, but have not been processed by the Contractor, and the names of any such Providers; and...

8.07 Other Reporting Requirements
The Contractor shall be required to notify the Division as soon as it has reason to believe that any provider may be insolvent, considering insolvency, or otherwise financially unstable."  Massachusetts MH/SAP Contract, Appendix B, pages 54-55, 61-63.

"5.1.1  Reimbursement Methodology for Members for the Second Contract Year...
C.  Risk Sharing
1.  The provisions for the financial risk sharing arrangement for service expenditures between the Division and the Contractor shall be as follows: ...
  d.  The Contractor shall prepare and submit to the Division, within ninety (90) days after the end of each contract year or as otherwise requested by the Division, a report  of actual service expenditures by Rating Category, which report shall include an estimate of claims incurred but not reported (IBNR) and an IBNR completion factor..."  Massachusetts MH/SAP Amendment 1, pages 7, 11.

"C.  Service Expenditures
1.  Monthly Reporting...
a.  The Contractor shall, by the fifteenth (15th) day of each month of the Contract, report in writing to the Division on the total monthly expenditures for services to Enrollees, separated into two categories as follows:
(1)  Service Expenditures for Recipients and
(2)  Service Expenditures for DMH Acute Care Consumers.

b.  The reports specified in Section 5.5.C.1.a. of Appendix A to this Contract shall detail services authorized; claims pended; claims denied; claims paid; estimated claims incurred but not reported (IBNR); average number of days between date of service and assignment of a transaction code number (TCN) stratified by type of service and provider; and average number of days between assignment of the TCN and claim adjudication stratified by type of service and provider; and shall be separated into the following categories:
(1)  For the first Contract Year, Members by Children and Families and Persons with Disabilities Rating Categories; for the second Contract Year, Members by Children and Families, Persons with Disabilities, and MassHealth Basic;
(2)   Inpatient and Diversionary Services for DMH Acute Care Consumers;
(3)  DEP or, in the alternative, ESP Services, whichever is applicable, to DMH Acute Care Consumers; and
(4)  All services for both Recipients and DMH Acute Care Consumers, by Provider.

c. The Contractor shall provide a monthly report summarizing service expenditures by date of payment, including both MIS generated and hand-generated payments, stratified by type of service and provider.

The Contractor shall provide the reports in this subsection in writing and on 3.5 inch diskette in a clearly labeled spreadsheet format fully compatible with Microsoft Excel or Lotus."  Massachusetts MH/SAP Contract, Appendix A, pages 72, 73. Massachusetts MH/SAP Contract Amendment 1, page 21.

General authorization

"8. Recordkeeping, Audit and Inspection of Records: ...
b) The Governor, the Secretary of Administration and Finance, the Comptroller, the State Auditor, the Attorney General, the Federal grantor agency, the Division and the Division's Secretary, or any of their duly authorized representative or designees shall have the right at reasonable times and upon reasonable notice to examine and copy, at reasonable expense, the books, records and other compilations of data of the Contractor which  pertain to the provisions and requirements of this Contract.  Such access shall include on-site audits, review, and copying of records."  Massachusetts MH/SAP Contract, page 2.

"C. Medical Records
The contractor shall: ...
  3. provide records at the Division's request for the following functions that include, but are not be limited to, monitoring the quality of care provided by the Contractor in accordance with federal law (e.g. 42 USC 1396a (a) (30)). Such records may also be requested by the Division, for the purpose of conducting performance evaluation activities of the Contractor as described under Section 5.1.C.4. of Appendix A to this Contract. Medical record audits conducted by the Contractor at the request of the Division may be subject to validation performed directly by the Division or its agent.

D. Data and Reporting Requirements
  1. On-line Data Requirements
  a. For the Division: The Contractor shall be required to provide designated Division staff with on-line access at all times to the Contractor's database files which shall include, but not be limited to, access to the following files: service authorization files; complaint, appeal, and grievance files; and paid, pended, and denied claims files for all Enrollees…"  Massachusetts MH/SAP Contract, Appendix A, pages 19-20.

Outcomes data

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

OUTCOMES MEASUREMENT
14. Review of Provider Practice - The Contractor will survey providers on their use of various outcomes measurement systems across providers of certain levels of care, exclusive of individual providers and group practices.  Such review will examine these outcomes measurement practices with respect to adults and children/adolescents for both mental health and substance abuse services.  The compliance target for this standard shall be the submission of a report by May 1, 2000…"  Massachusetts MH/SAP Contract, Amendment 6, page 8.

Performance data

"D. Provider Performance
the Contractor shall report on the following: performance of Network Providers for access, appropriateness of care, continuity of care, cost efficiency, conformance with performance requirements, and treatment outcomes."  Massachusetts MH/SAP Contract, Appendix B, page 59.

"Section 5 of Appendix A of the Contract is amended by inserting the foiling new Section 5.1.3.G...
Section 5.1.3.G: Performance Incentives, Penalties, and Initiatives: Provisions and Standards

1. General Provision...
For purposes of the fourth Contract Year, the Contractor shall submit to the Division draft methodologies including documentation necessary to support said methodologies and the time period for measuring the performance under each Performance Standard and Initiative by the following dates:
  (i) methodologies for one third (1/3) of the Performance Standard and Invites must be submitted no later than the close of business September 15, 1999;
  (ii) methodologies for one third (1/3) of the Performance Standard and Initiatives must be submitted no later than the close of business October 15, 1999;
  (iii) methodologies for the final third (1/3) of the Performance Standards and Initiatives must be submitted no later than the close of business November 15, 1999."  Massachusetts MH/SAP Contract, Amendment 6, pages 1-2.

Utilization data

"8.0 Reporting
The Contractor shall submit for division prior proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis to the division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

A.  Claims Processing
The Contractor shall report: ...
  4.  Expenditure and utilization data by date of service for Enrollees, stratified by type of service, Region, DMH Acute Care Consumers, and Recipient Rating Category...

B.  Service Authorization and Utilization Review
The Contractor shall report the following stratified by Recipients, Recipient age, Recipient Rating Category, DMH Acute Care Consumers, and by type of service (mental health versus substance abuse):
  1.  number of approved inpatient admissions;
  2.  number of inpatient admissions which were diverted to alternative services;
  3.  number of denied inpatient admissions; and
  4.  number of denied inpatient continued stay requests; and
  5.  number of denied requests for Outpatient Service authorization...

8.04  Quarterly Reporting
The Contractor shall deliver quarterly reports regarding the information set forth below, to the division no later than the 20th day of the month following the end of the quarter.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in appendix A to this Contract...

G.  Special Service for Substance Abuse Pregnant Women
The Contractor shall report on utilization and expenditures for each type of service and by Provider...

8.05  Semi-annual Reporting
The Contractor shall provide semi-annual reports to the Division no later than the 20th day following the end of semi-annual reporting period designated by the Division. Failure to meet this deadline for submissions of these reports may result in the assessment of financial sanctions as set forth in Appendix A to this Contract.

The Contractor shall:
  a.  submit written reports on Quality Management activities pursuant to the requirements set forth in Section 6 of Appendix B to this Contract herein;
  b.  report the total number of requests for inpatient admissions which were diverted to alternative services, stratified by Enrollee age, service category (mental health or substance abuse), primary diagnosis, Region, Network Provider, including common reasons for diversions and case outcomes;
  c.  report a listing of inpatient and outpatient diagnoses by frequency, with corresponding service expense data..."  Massachusetts MH/SAP Contract, Appendix B, pages 54, 57-60.

"PSYCHOPHARMACOLOGY
16. Pharmacy Profiling - The contractor shall complete a study, using pharmacy, medical service and behavioral  health claims data, on the service utilization patterns of members enrolled with the Contractor who are receiving certain psychotherapeutic medications, with a particular emphasis on appropriate dosing and refill practices and their correlation with health care utilization.  The compliance target shall be the submission of a report, by June 30, 2000, on the results of the study, including policy recommendations on strategies to improve the health care utilization patterns of the identified cohort."  Massachusetts MH/SAP Contract, Amendment 6, page 9.

Other

"2.06.06  Fraud Detection and Response Program...
D.  Reporting Requirements
The Contractor shall submit a monthly report on any new fraud referrals made pursuant to Section 2.06.06.B. of this Appendix B to the Contract during the reporting month but not yet closed, and a report that indicates all cases closed during the month.  These reports shall be submitted to the Division during the first week of the month, reflecting the activities of the previous month.  Any monies recovered during the previous month from a Network and/or non-Network Provider will be reflected in this report.

On a quarterly basis, the Contractor shall provide a  summary of the monthly information to reflect quarterly and year-to-date data and will be compared to previous periods to give some indication of trends or other issues that may require management action on the part of the Contractor or the Division.  The quarterly reports will be submitted by the 15th of October, January, April and July to summarize the previous three months' information."  Massachusetts MH/SAP Contract, Appendix B, pages 20-22.

"4.0  ACCESS AND AVAILABILITY
The Contractor shall: ... 4.01.08  Develop a report to monitor by Provider the number of Enrollees who transfer their care from one Provider to another Provider, evaluate the reasons for the transfer, take corrective action if required, and submit a quarterly report to the Division which shall include, the number of transfers by Enrollee and Provider, the reasons for the transfers, and corrective action Plans implemented or to be implemented."  Massachusetts MH/SAP Contract, Appendix B, pages 26, 27.

“8.01 Same Day Reporting
The Contractor shall provide on a daily basis a report of Critical Incidents for hospitalized Enrollees…

8.02 Next Day reporting
The Contractor shall provide a report of Serious Incidents for Enrollees within 24 hours of such Serious Incident…”  Massachusetts MH/SAP Contract, Appendix B, page 55.

Care process and outcome data for mental health and substance abuse treatment

"8.0  REPORTING
The Contractor shall submit for Division prior  proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.04  Quarterly Reporting
The Contractor shall deliver quarterly reports regarding the information set forth below, to the Division no later than the 20th day of the month following the end of the quarter.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

C.  Intensive Clinical Management
The Contractor shall report for each ICM case the following:
1.  administrative and service cost stratified by Enrollee, age, sex, Region;
2.  level of functioning upon entry to the ICM Program and upon discharge from the ICM Program;
3.  percent of treatment goals that are attained within the period of time allotted from the time the Enrollee enters treatment to the time of discharge from treatment; and
4.  average duration of participation in the ICM by calendar weeks.

D.  Provider Performance
The Contractor shall report on the following: performance of Network Providers for… appropriateness of care, continuity of care, conformance with performance requirements, and treatment outcomes...

F.  Service Access and Outcome Measures:
The Contractor shall report the following:
1.  readmission rate within 7, 30, 60, and 90 days of discharge by type of service and Enrollee;
2.  number and percentage of face-to-face evaluations performed within sixty minutes of referral and presentation to an ESP or DEP;
3.  number and percentage of times that a psychiatrist responds by telephone or in person within fifteen minutes of receiving a request from an ESP or a DEP to perform a psychiatric consult on an Enrollee;
4.  number of Enrollees diverted from inpatient hospitalization who are hospitalized within 7, 30, 60, and 90 days by type of service and Enrollee;
5.  number of admissions stratified by type of service;
6.  number of patient days stratified by type of service;
7.  number of admissions per l000 Enrollees stratified by type of service;
8.  number of patient days per 1000 Enrollees stratified by type of service;
9.  number of admissions outside of the Provider Network stratified by type of service;
10.  average length of stay stratified by type of service, Region, Provider, mental health, substance abuse, including a separate breakout of ICM Enrollees;
11.  number of Enrollees discharged from an inpatient facility who receive Outpatient Services within three days of discharge from the inpatient facility;
12.  number of Enrollees receiving mental health or substance abuse services, or both, ninety days following discharge from an inpatient facility;
13.  number of episodes in which Enrollees were restrained during a stay in an inpatient facility; and
14.  number of episodes in which Enrollees were placed in seclusion during a stay in an inpatient facility."  Massachusetts MH/SAP Contract, Appendix B, pages 54, 57-59.

Discharge data for addictive disorder

"8.0  REPORTING
The Contractor shall submit for division prior proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis to the Division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

C.  Discharge Planning
The Contractor shall:
Report the number of administratively necessary days stratified by Recipient Rating Category and age, DMH Acute Care Consumers and age, Provider, and Region."  Massachusetts MH/SAP Contract, Appendix B, pages 54-56.

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

SERVICES/SYSTEM INTERACTION
5. Medication Monitoring - The Contractor shall measure the percentage of adult mental health inpatient discharge events followed by a medication appointment within 14 business days of discharge…"  Massachusetts MH/SAP Contract, Amendment 6, page 4.

Hospitalization for addictive disorder

"8.0  REPORTING
The Contractor shall submit for Division prior  proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis  to the Division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in  Appendix A to this Contract...

B.  Service Authorization and Utilization Review
The Contractor shall report the following stratified by Recipients, Recipient age, Recipient  Rating Category, DMH Acute Care Consumers, and by type of service (mental health versus substance abuse):
1.  number of approved inpatient admissions
2.  number of inpatient admissions which were diverted to alternative services;
3.  number of denied inpatient admissions; and
4. number of denied inpatient continued stay requests..."  Massachusetts MH/SAP Contract, Appendix B, pages 54-56.

Hospitalization for mental illness

"8.0  REPORTING
The Contractor shall submit for Division prior  proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis  to the Division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in  Appendix A to this Contract...

B.  Service Authorization and Utilization Review
The Contractor shall report the following stratified by Recipients, Recipient age, Recipient  Rating Category, DMH Acute Care Consumers, and by type of service (mental health versus substance abuse):
1.  number of approved inpatient admissions
2.  number of inpatient admissions which were diverted to alternative services;
3.  number of denied inpatient admissions; and
4.  number of denied inpatient continued stay requests..."  Massachusetts MH/SAP Contract, Appendix B, pages 54-56.

Identified substance abuse

"8.0  REPORTING
The Contractor shall submit for Division prior  proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

F.  Service Access and Outcome Measures:
The Contractor shall report the following: ...
12.  number of Enrollees receiving mental health or substance abuse services, or both, ninety days following discharge from an inpatient facility..."  Massachusetts MH/SAP Contract, Appendix B, pages 54, 58-59.

QA/Utilization measures for mental health/substance abuse treatment

"8.0  REPORTING
The Contractor shall submit for Division prior proposed formats for all reports, as set forth herein, within thirty days after the Full Service Start Date...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis to the division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this contract.

A.  Claims Processing
The Contractor shall report: ...
4.  Expenditure and utilization data by date of service for enrollees, stratified by type of service, Region, DMH Acute Care Consumers, and Recipient Rating Category...

B.  Service Authorization and Utilization Review
The Contractor shall report the following stratified by Recipients, Recipient age, Recipient Rating category, DMH Acute Care Consumers, and by type of service (mental health versus substance abuse):
1.  number of approved inpatient admissions:
2.  number of inpatient admissions which were diverted to alternative services;
3.  number of denied inpatient admissions; and
4.  number of denied inpatient continued stay requests; and
5.  number of denied requests for Outpatient Service authorization...

8.04  Quarterly Reporting
The Contractor shall deliver quarterly reports regarding the information set forth below, to the division no later than the 20th day of the month following the end of the quarter.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in appendix A to this contract...

E.  Service Authorization
The Contractor shall report:  Outpatient Service utilization, including, but not limited to, average number of Outpatient Service visits per patient, average number of Outpatient Service visits per episode of care, and number of Outpatient Service authorization requests stratified by Provider, which were approved, modified, or denied."  Massachusetts MH/SAP Contract, Appendix B, pages 54, 57-58.

"G.  Special Service for Substance Abuse Pregnant Women
The Contractor shall report on utilization and expenditures for each type of service and by Provider...

8.05  Semi-annual Reporting
The Contractor shall provide semi-annual reports to the division no later that the 20th day following the end of the semi-annual reporting period designated by the Division.  Failure to meet this deadline for submission of these reports may result in the assessment of financial sanctions as set forth in Appendix a to this Contract...

The Contractor shall:
a.  submit written reports on Quality Management activities pursuant to the requirements set forth in Section 6 of appendix B to this Contract herein;

b.  report the total number of requests for inpatient admissions which were diverted to alternative services, stratified by Enrollee age, service category (mental health of substance abuse), primary diagnosis, Region, Network Provider, including common reasons for diversions and case outcomes;

c.  report a listing of inpatient and outpatient diagnoses by frequency, with corresponding service expense data..." Massachusetts MH/SAP Contract, Appendix B, pages 59-60.

Other

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

SERVICES/SYSTEM INTERACTION
5. Medication Monitoring - The Contractor shall measure the percentage of adult mental health inpatient discharge events followed by a medication appointment within 14 business days of discharge…"  Massachusetts MH/SAP Contract, Amendment 6, page 4.

Reserve

“B. Business Requirements…
5. Additional Financial Requirements
  a. Prior to the Full Service Start Date, and, subsequently on request by the Division, Contractor shall be required to submit documentation about the Contractor’s financial condition, including but not limited to: …
  (2) proformance statements for the two most recent fiscal years and two of the following: …
  b) evidence, consisting of proof of a bank credit line or other non-contract sources, of ability to sufficiently fund at least two months of program operation;
  c) proof of an acceptable credit rating or nationwide business credit rating from a bureau such as Dun & Bradstreet…”  Massachusetts MH/SAP Contract, Appendix A, pages 71, 73-74.

"5.7 Financial Instability Plan
A. To ensure payment to Providers for Recipient and DMH Acute Care Consumer services and payment of administrative costs in the event of  the Contractor's insolvency, the Contractor shall provide the Division with the following on the first day of the term of this Contract:
  1.  Promissory note for  $2,000,000, which shall be held by the Division through the end of the sixth month following the end of the final Contract Year, to be used to pay service claims pursuant to the risk-sharing provisions of this Agreement."  Massachusetts MH/SAP Contract, Appendix A, page 77.

“PERFORMANCE BOND; GUARANTEE
If awarded the Contract, the Bidder agrees to the following:
The Contractor shall be required to provide a performance bond of standard commercial scope issued by a surety company doing business in this State, an irrevocable letter of credit, or a cash deposit (‘Performance Bond’) to the Division for as long as the Contractor has outstanding liabilities relating to the Contract of $50,000 or more…

In the event of a default by the Contractor under the Contract and in declaration of such default to the holder of the Performance Bond by the Division, the Division shall, in addition to any other remedies it may have under the Contract, obtain payment under the Performance Bond or substitute security for the purpose of the following: …

In the event the Division agrees to accept substitute security in lieu of the Performance Bond, irrevocable letter of credit or cash deposit, the Contractor agrees to execute any and all documents and perform any and acts necessary to secure and enforce the Division’s security interest in such substitute security including, but not limited to, security agreements and necessary UCC filings pursuant to the Massachusetts Uniform Commercial Code…

AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance bond shall be equal to $16.5 million (sixteen million and five hundred thousand dollars) or as otherwise established by the Division…
If there is an increase of the Capitation Rate payment that exceeds 10% of the Performance Bond amount, the Division may require an increase in the amount of the Performance Bond…”  Massachusetts MH/SAP Contract, Appendix U, pages 1-2.

“APPENDIX X:
Appendix X shall be amended as follows: the Contractor shall submit, for the Division’s prior review and approval, a proposed new Performance Bond and new Guaranty, reflecting the change in the partners that comprise the Partnership, as required under the Contract, section 6.2.B.a. of Appendix A.  Such new performance bond shall either be for an additional amount of $3.5 million, together with a letter from the issuing insurance company for the original bond stating that the original bond complies with all relevant Contract requirements, which letter shall be subject to the Division’s prior approval; or shall be for a total amount of $19.5 million, shall comply with all relevant Contract requirements, and shall in such instance replace the original bond…”  Massachusetts MH/SAP Contract, Amendment 2, page 7.

Limits on allowable administrative costs

"D.  Risk Sharing
1.  Administrative...
c.  If the Contractor's Administrative Expenses are less than the Administrative Budget, than the Contractor shall be allowed to retain the difference between Administrative Expenses and the Administrative Budget in an amount not to exceed 10% of actual Administrative Expenses..."  Massachusetts MH/SAP Contract, Appendix A, page 56.

"5.2  Reimbursement Methodology for DMH Acute Care Consumers...
A.  Compensation Rates...
2.  Administrative Compensation Rate:
  a.  During the first Contract Year, the Administrative Compensation Rate shall be based upon the first Contract Year budget of  $1,027,457, subject to DMH appropriation and availability of funds, provided, however, that actual costs shall be reconciled pursuant to the provisions of  Section 5.2.D.1.c. of Appendix A to this Contract, herein.  The total Administrative Compensation Rate Budget (‘Administrative Compensation Rate Budget') shall be equal to the sum of the following items:  Direct Costs; Indirect Costs; and Earnings at a rate of 8%; and furthermore, shall not exceed $1,027,457…"  Massachusetts MH/SAP Contract, Appendix A, page 51.

5.2.A.2a(ii):  During the second contract Year, the Administrative Compensation Rate shall be based upon the second Contract Year budget of $1,068,808, subject to DMH appropriations and availability of funds, provided, however, that the actual costs shall be reconciled pursuant to the provisions of Section 5.2.D.1.c of Appendix A of the Contract.  The total Administrative compensation Rate Budge (‘Administrative compensation Rate Budget') shall be equal to the sum of the following items:  direct costs; indirect costs; and earnings at a rate of 8%; and furthermore, shall not exceed $1,068,808…"  Massachusetts MH/SAP Contract, Appendix A, page 36.

"B.   Administrative Services...
4.  If the Division determines that the administrative component of the Capitation Rate and the Administrative Compensation Rate payments exceeded the respective actual administrative costs... then the Division shall determine the amount of administrative savings for the period.  The Division shall be entitled to the savings from the administrative component of the Capitation Rate.  Savings from the Administrative Compensation Rate shall be apportioned in accordance with the provisions of Section 5.2.D.1.c of Appendix A to the Contract...

6.  If the Division determines that the administrative component of the Capitation Rate and the Administrative Compensation Rate payments exceed the respective actual administrative costs, the Division may direct the Contractor to increase administrative expenditures, in a manner directed by the Division and not to exceed the maximum amounts established in Sections 5.1.A. and 5.2.A. of this Appendix A to the Contract."  Massachusetts MH/SAP Contract, Appendix A, pages 70-72.

"5.1.1  Reimbursement Methodology for Members for the Second Contract Year...
A.  Capitation Rates...
5.  Administrative Component of the Capitation Rate
  a.  The administrative component of the Capitation Rate shall be, subject to the provisions of section 5.5.B of Appendix A to this Contract, based upon the second Contract Year budget of $15,731,192 for the administrative services budget (‘Standard Budget')...
  d.  The total administrative services budget of $17,409,186 (‘Administrative Services Budget') during the second Contract Year shall be equal to the sum of the following components:
   (i) direct costs,
   (ii) indirect costs, and
   (iii) earnings.

Unless the Division establishes an Adjusted Expansion Budget, the amounts of each component shall not exceed the following, unless otherwise approved by the Division, in writing:
  1)  Direct costs:  no more than $14,971,335;
  2)  Indirect costs:  no more than $1,148,282;
  3) Earnings:  no more than $1,289,569."  Massachusetts MH/SAP Contract, Amendment 1, pages 7-9.

“2. Section 5.5.B. shall be amended by adding the following new subsection 8, as follows:
5.5.B.8.:  Not withstanding any other provision herein to the contrary, if the Division determines that the administrative component of the Capitation Rate exceeds actual administrative cost (‘Excess Payment’), the Division may, in its sole discretion, direct the Contractor to retain a portion of any such Excess Payment and apply it in a manner and for other contract purposes as specifically designated by the Division.”  Massachusetts MH/SAP Contract, Amendment 4, page 30.

“1. Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3 (such section to be inserted between Section 5.1.2 and Section 5.2):
Section 5.1.3 Reimbursement Methodology for Members for the Fourth Contract Year Payment for the fourth Contract Year by the Division to the Contractor for Members shall be as follows: …

5. Administrative Component of the fourth Contract Year Capitation Rate…
  b. the total Administrative Services Budget during the fourth Contract Year shall be equal to the sum of the following components:
 (i) direct costs,
 (ii) indirect costs, and
 (iii) earnings.

Unless otherwise approved by the Division in writing, the amounts of each components shall not exceed the following:
  1) Direct costs: no more that $17,320,006
  2) Indirect costs: no more that $1,482,593.”  Massachusetts MH/SAP Contract, Amendment 5, pages 2-3.

MIS requirements

"9.0 MANAGEMENT INFORMATION SYSTEMS…
9.01 Management Information Systems
Through its MIS, the Contractor shall perform the following:
  a.  pay Providers under contract for services rendered to Enrollees;
  b.  receive data from the Division on an IBM standard label 6250 BPI tape or 3480 compatible ½ inch tape cartridge;
  c.  be able to receive from the Division an initial file(s) of Enrollees, including, Recipients and Group B DMH Acute Care Consumers;
  d. be able, one month prior to the start date of the first Contract Year, to receive from the Division an initial file of providers under contract with the current MCO;
  e. establish a Frame-Relay, TCP/IP connection via the MCI data network with the Division's claims processing vendor (Unisys, Somerville, MA) for the purposes of file transfers between Unisys and the Contractor (e.g., eligibility updates) and interactive access by the Division in Boston to the Contractor's MHS system;
  f.  ensure that ESP's/DEP's have access to REVS at EDS*
  g. work with the Division and whoever DMA designates to establish appropriate networking technology to be used in administering the MH/SAP.
  h.  receive from the division and process Enrollee and Provider eligibility updates nightly utilizing the network specified above and the File Transfer Protocol (FTP).
  i.  work with the technical staff of DMA, DMH and the Division's claims processing vendor (Unisys, Somerville, MA) to establish and maintain links and ongoing operation procedures to ensure timely and accurate transfer of data;
  j.  make modifications as required by the Division to subsections a. through i. set forth above to accommodate the Division's changes in its claims processing system from the vendor the Division currently subcontracts with for claim processing, to another vendor, or to its own claim processing system;
  k. provide billing forms or electronic media formats with appropriate billing instructions to Providers including, but not limited to, a description of the use of procedure codes as approved by the Division;
  l.  provide the Division with a tape within three business days of the close of each month, containing records of all paid original claims and or paid original claims adjustments for services provided to Recipients;
  m.  provide the Division with a tape within three business days of the close of each month, containing records of all paid original claims for services provided to DMH Acute Care Consumers; and
  n.  obtain a list of provider numbers from the Division to be issued to new Providers which shall prevent duplicate billing to the Division."  Massachusetts MH/SAP Contract, pages 63-64.

"5.1.1C.5:  PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
2)  Automated Eligibility Process:  Phase II
By June 30, 1998, the Contractor shall through MHS, add PCP information, demographic and TPL changes received from DMA, test the merge process and through automation, recycle the reject file.  If the systems specifications are reviewed and approved by DMA and merge process is tested, the Division will reimburse the Contractor for actual incremental administrative costs up to $124,500..."  Massachusetts MH/SAP Contract, Amendment 5, pages 14, 19.

Other

"14. Anti-Boycott Warranty.  During the term of this Contract, neither contractor nor any ‘affiliated company’ as hereafter defined, shall participate in or cooperate with an international boycott, as defined in Section 999 (b) (3) and (4) of the Internal Revenue code of 1954, as amended by the Tax Reform Act of 1986, or engage in conduct declared to be unlawful by Sections 2 and 3 of chapter 151E, Massachusetts General Laws.  As used herein, an ‘affiliated company’ shall be any business entity of which at least 51% of  the ownership interests are directly or indirectly owned by the Contractor or by a person persons or business entities which directly or indirectly own at least 51% of the ownership interests of the Contractor.

15. Certification.  By signing below the Contractor certifies under the pains and penalties of perjury that pursuant to M.G.L c.62c, s.49A, the contractor has filed all state tax returns, paid all taxes and complied with all laws of the Commonwealth relating to taxes; and that pursuant  to M.G.L c.151 s.19A, the Contractor has compiled with all laws of the Commonwealth relating to contributions and payments in lieu of contributions to the Employment Security System; and pursuant to the provisions of M.G.L c.7A S.6, that the names of all person having a financial interest in the Contract appear below as follows: (This shall not include any person whose financial interest consists of the holding of one percent (1%) or less or the capital stock of a corporation contraction to provide the service herein.  Attach additional sheets as necessary.): …

26. Insurance.  Unless otherwise provided by law, the Contractor shall provide, maintain and require its subcontractors to provide and maintain all insurance for its employees, including disability, worker’s compensation and unemployment compensation, in accordance with the statutory requirements of any state where work is performed.  The contractor shall provide adequate proof of the fulfillment of any of the requirements of this section to the Division within seven (7) days of its receipt of a written request…”  Massachusetts MH/SAP Contract, pages 3-5.

“B. Business Requirements
1. The Contractor hereby represents and warrants that the following are true and accurate at all time during this contract:
  a. the Contractor is organized primarily for the purpose of administering and coordination the delivery of health care services;
  b. the Contractor, its general partners and its parents; subsidiary(ies), and other related organization(s) if any, do not own, operate, manage, contract or otherwise engage in any business with any entity which delivers or manages the delivery of Covered Services listed in Appendix C to this Contract to Enrollees under the Contract…

3. Interests and Related Organizations
  a. The Contractor shall have no interest at any time during this Contract that conflicts  with the performance of services required under this Contract…”  Massachusetts MH/SAP Contract, Appendix A, page 71.

Internal grievance process

"3.0  CUSTOMER SERVICES
The Contractor shall: ...
3.05  Develop and submit to the Division for prior review and approval complaint policies and procedures, to be implemented on the Full Service Start Date, which shall, at a minimum, include, but not be limited to:

a.  a process to provide the Customer Service Department staff with orientation and training in the complaint policies and procedures on the Full Service Start Date and on an ongoing basis;
b.  a system to date and log receipt of both verbal and written complaints, as well as procedures to provide written acknowledgment of the receipt of the written complaint within 24 hours;
c.  a process for the review and resolution of complaints which shall include, at a minimum, a requirement for a written decision by the Contractor within fifteen (15) working days of receipt of the complaint;
d. further mechanisms of appeal if there is continued  dissatisfaction with the initial resolution; and
e.  correspondence to provide Enrollees and Enrollees' guardians notification of the receipt of a complaint, resolution, and further mechanisms of appeal."  Massachusetts MH/SAP Contract, Appendix B, pages 24-25.

"7.0  APPEALS AND GRIEVANCES
The Contractor shall:
7.01  Maintain written policies and procedures for the filing, receipt, prompt resolution, and documentation of any and all appeals and grievances of service authorization decisions for Covered Services brought by Enrollees, Enrollees' family members, or Providers on behalf of Enrollees.  Such policies and procedures shall be approved by the Division, and include, at a minimum, the following:

a. a standardized appeals and grievance process, a means for assessing and categorizing the nature and seriousness of the appeals and grievances, and timeframes for responses;
b. a mechanism for informing Enrollees of the appeals and grievance procedures;
c.  a mechanism for directly acknowledging to Enrollees the receipt of any and all appeals and grievances within 24 hours of receipt of any appeal or grievance;
d. a provision to ensure confidentiality of the appeals and  grievance process;
e. at least two levels of review by qualified clinicians of the appropriate specialty, with the requirement that the second level of review shall be performed by the Medical Director or an Assistant Medical Director in the appropriate specialty; and
f.  a provision to inform the Recipient of his/her right to a hearing before the Division's Board of Hearings (BOH), if the Recipient remains dissatisfied with the second level of review decision...

7.02 Create and maintain an appeals and grievance log to document the type and nature of each appeal and grievance, how each appeal or grievance was addressed and what, if any, corrective action was taken.

7.03  Review the appeals and grievances policies and procedures at least annually, for the purpose of making amendments to improve the policies and procedures.

7.04  Designate a staff person(s) as the Enrollee ombudsman who will be responsible for the coordination of the receipt and processing of appeals and grievances.

7.05  Designate a staff person to appear before the BOH for all Recipient appeals and grievances pertaining to service denials or diversions..."  Massachusetts MH/SAP Contract, Appendix B, pages 53-54.

Time lines for grievance response

"3.0  CUSTOMER SERVICES
The Contractor shall: ...
3.05  Develop and submit to the Division for prior review and approval complaint policies and procedures, to be implemented on the Full Service Start Date, which shall, at a minimum, include, but not be limited to: ...
c.  a process for the review and resolution of complaints which shall include, at a minimum, a requirement for a written decision by the Contractor within fifteen (15) working days of receipt of the complaint..."  Massachusetts MH/SAP Contract, Appendix B, pages 24-25.

"7.0  APPEALS AND GRIEVANCES
The Contractor shall:
7.01 Maintain written policies and procedures for the filing, receipt, prompt resolution, and documentation of any and all appeals and grievances of service authorization decisions for Covered Services brought by Enrollees, Enrollees' family members, or Providers on behalf of Enrollees.  Such policies and procedures shall be approved by the Division, and include, at a minimum, the following: ...
a. ... timeframes for responses..." Massachusetts MH/SAP Contract, Appendix B, page 53.

External appeal to state

"7.0  APPEALS AND GRIEVANCES
The Contractor shall:
7.01  Maintain written policies and procedures for the filing, receipt, prompt resolution, and documentation of any and all appeals and grievances of service authorization decisions for Covered Services brought by Enrollees, Enrollees' family members, or Providers on behalf of Enrollees.  Such policies and procedures shall be approved by the Division, and include, at a minimum, the following: ...

f.  a provision to inform the Recipient of his/her right to a hearing before the Division's Board of Hearings (BOH), if the Recipient remains dissatisfied with the second level of review decision."  Massachusetts MH/SAP Contract, Appendix B, page 53.

“14. The following section 5.9 shall be added after 5.8 and shall be entitled:
‘Medical Necessity Determination’:
If either the division’s Board of Hearings or a court of competent jurisdiction determines or issues a ruling to the effect that a particular service provided to or sought by a Member, or a provider on the Member’s behalf, is or was medically necessary, then the Contractor shall pay for that service provided, however, that  the requirements of this subsection shall be subject to the Contractor’s billing rules as set forth in the Contractor’s provider manual, as approved by the Division, except as may otherwise be require by Contract or by law.”  Massachusetts MH/SAP Contract, Amendment 2, page 7

Grievance process for providers

“2.05.06 Develop and implement an appeals policy and procedure to review and resolve denied claims and payment disputes, to be implemented within the first sixty (60) days of the first Contract Year, subject to prior review and approval by the Division, and which shall include, at a minimum, but not be limited to the following:

  a. written policies and procedures for the filing, receipt, prompt resolution, and documentation of any and all appeals brought by a Provider;
  b. a means for assessing and categorizing the denied claims and payment disputes;
  c. timeframes for resolution and response by the Contractor; and
  d. clear instructions that Providers do not have a right to an appeal through the Division…

2.05.06a(2) Ensure that all appeals policies and procedures for providers which the Contractor is required to develop under Section 2.05.06 of Appendix B and elsewhere in this Contract are consistent with industry standards for such policies and procedures.”  Massachusetts MH/SAP Contract, Appendix B, page 18.

Provider selection standards

"2.02  Provider Credentialing
The Contractor shall:
2.02.01  Develop a credentialing process... which shall be carried out during the initial procurement of the Provider Network, once the MH/SAP operations begin, and whenever a new Provider is added.  At a minimum, a recredentialing process shall occur annually for Providers...

2.02.04  Ensure that the basic components of the credentialing process at a minimum include, but are not limited to, the following:
  a.  licensing, accreditation, certification, training, specialty board eligibility or certification;
  b. current status of professional license, restrictions and history of any loss of license in any state;
  c.  DEA number and copy of certification;
  d.  hospital privileges, name of hospitals, and scope of privileges;
  e.  malpractice insurance, carrier name, amount of coverage, copy of the face sheet and scope of coverage;
  f. malpractice history, pending claims, and successful claims against the Provider;
  g.  record of continuing professional education;
  h. Medicare, Medicaid, Federal Tax ID Number, and Social Security Number;
  i.  location and telephone numbers of all office, hours of operation, and provisions for emergency care and backup;
  j.  areas of special experience, skills and training;
  k. cultural and linguistic capabilities;
  l.  review of practice patterns;
  m. review of member satisfaction and any grievances that may have been filed against the provider within the past two years;
  n.  physical accessibility for persons with disabilities;
  o.  reference check;
  p.  face to face interviews; and
  q.  a site visit.

2.02.05  Ensure that the minimum credentialing requirements for Providers by type and service of Provider including the following:
  a.  Psychiatrist - shall hold an MD or DO degree, an unrestricted medical license in the Commonwealth of Massachusetts, and eligibility or certification by American Board of Psychiatry and Neurology; Psychiatrists providing services to children 13 years old or younger shall be board eligible or board certified in child psychiatry;
  b. Psychologist - shall hold a Ph.D., Ed.D., Psy.D. in Psychology and have an unrestricted license in the Commonwealth of Massachusetts and a clinical specialist certification in psychiatric nursing or demonstrate experience equivalent to the certification requirements.
  c.  Nurse - shall hold an unrestricted/complete license as a Registered Nurse in the Commonwealth of Massachusetts and a clinical specialist certification in psychiatric nursing or demonstrate experience equivalent to the certification requirements. Nurses providing medication management visits, including but not limited to, prescribing medications, shall hold a Masters of Science Degree in Mental Health or Psychiatric Nursing and hold a clinical specialist certification in psychiatric nursing;
  d.  Social Worker - shall hold a Master of Social Work degree or equivalent degree and license in the Commonwealth of Massachusetts;
  e.  Mental Health Counselors - shall hold a Masters level degree in Counseling such as Psychology, Rehabilitation Counseling, Counseling Education, Psychology Counseling, and/or Marriage and Family Counseling;
  f.  Substance Abuse Counselor - shall be certified as an alcohol or chemical dependency counselor, or both, or demonstrate experience and education equivalent to certification requirements;
  g.  Hospital - shall be licensed by the appropriate state agency and be JCAHO accredited;
  h.  Freestanding Detoxification Program - shall be licensed by the appropriated state agency;
  i.  Methadone Maintenance Program - shall be licensed by the appropriate state agency; and
  j.  Mental Health Clinic - shall be licensed by the appropriate state agency.

Other types of providers may be included in the Provider Network, provided minimum credentialing requirements for each type of provider are developed and submitted for prior review and approval by the Division.

2.02.06  Unless specifically waived in writing by the Division in each instance,  any Provider rendering Covered Services as set forth in Appendix C to this Contract, shall meet minimum credentials outlined in Section 2.02.05 of Appendix B to this Contract..."  Massachusetts MH/SAP Contract, Appendix B, pages 7-10.

Provider termination standards

"2.03  Network Administration
The Contractor shall:
2.03.01  Develop, submit to the Division for review and prior approval and maintain a Provider policy and procedure manual which shall be distributed to the Providers no later than the sixth month of the first Contract Year, and which shall, at a minimum... delineate the role and responsibilities of the Provider and Contractor which shall include, but not be limited to, the following: ...
j.  Provider agreement termination criteria."  Massachusetts MH/SAP Contract, Appendix B, pages 13-14.

"2.06 Network Management
The Contractor shall: ...
2.06.05 Establish a plan, subject to the Division's prior review and approval, prior to the Full Service Start Date, for taking appropriate management action with Providers whose performance is determined to be unacceptable by the Network Management Department.

2.06.05A. At the direction of the Division, terminate or take other appropriate management action with Providers who may be insolvent or otherwise financially unsound.

2.06.06 Fraud Detection and Response Program
Develop and implement a Fraud Detection and Response Program within the first nine months of the first Contract Year, and submit the plan to the Division for its prior review and approval. The Fraud Detection and Response Program shall, at a minimum, include the following elements: ...

C. Fraud Response
The contractor Shall: ...
6. Terminate a non-compliant Provider from the Contractor's Network."  Massachusetts MH/SAP Contract, Appendix B, pages 19-21.

Prohibition on plan delegation of liability to subcontractor

"17.  Subcontracting.  None of the services to be provided by the Contractor pursuant to this Contract shall be subcontracted or delegated in whole or in part to any other organization, association, individual, corporation, partnership or other such entity without the prior written approval of the Division.  No subcontract or delegation shall relieve or discharge the Contractor from any obligation or liability under this Contract except as specifically set forth in the instrument of approval..."  Massachusetts  MH/SAP Contract, page 5.

"B.  Delegation to Subcontractors
The Contractor shall: ...
5.  remain fully responsible for meeting all of the terms and requirements of the Contract.  No Provider Agreement, subcontract or other agreement with providers shall operate to relieve the Contractor of its legal responsibilities under the Contract."  Massachusetts MH/SAP Contract, Appendix A, pages 18-19.

Restrictions on physician incentive agreements

"5.3 Contractor Reimbursement of Network Providers...
B. Other Forms of Risk Sharing...
2. Any Provider reimbursement methodologies proposed to the Division by the Contractor must satisfy the following minimum requirements:
  a. balance cost incentives with access and quality incentives; and
  b. ensure that the Providers the Contractor is proposing to receive such reimbursement methodologies be able to demonstrate the managerial, operational, and financial capability of managing the requested risk arrangement."  Massachusetts MH/SAP Contract, Appendix A, pages 59-60.

Scope of duties delegated to subcontractors

"Insurance. Unless otherwise provided by law, the Contractor shall provide, maintain and require its subcontractors to provide and maintain all insurance for its employees, including disability, worker's compensation and unemployment compensation, in accordance with the statutory requirements of any state where work is performed…"  Massachusetts MH/SAP Contract, page 5.

"B. Delegation to Subcontractors
The Contractor shall: ...
4.  include the following language in all Provider Agreements, agreements with non-Network providers and other agreements with providers:
'Providers shall not seek or accept any payment from any Recipient for any Covered Services rendered, nor shall providers have any claim against, or seek any payment from the Division. Instead, providers shall look solely to the Partnership for payment with respect to Covered Services rendered to Recipients. Furthermore, providers shall not maintain any action at law or in equity against any Recipient or the Division to collect any sums that are owed by the Partnership under this Agreement, for any reason, even in the event that the Partnership fails to pay, becomes insolvent or otherwise breaches the terms and conditions of this Agreement. This Section shall survive termination of this Agreement' (where 'Agreement' shall refer to the agreement between the Contractor and any subcontractor and where 'provider' shall refer to the subcontractor, including Network and non-Network providers, with whom the Contractor is contracting,)…"  Massachusetts MH/SAP Contract, Appendix A, pages 18-19.

Adjustment in payment

"4.  Cash Transfers
K.  In the event that audit findings made pursuant to this Contract of DSRA and/or CCA operation indicate, in the Division's determination, that the Contractor has failed to comply with any provision of this Contract, the Division may elect to impose additional controls on the Contractor's access to the DSRA and/or the CCA, including but not limited to adjusted cash transfer schedules...withholding incentive payments and bonuses.  The division may impose these limits and withhold until such time as audit-identified deficiencies are demonstrably corrected..."  Massachusetts MH/SAP Contract, Appendix A, pages 66, 69.

"6.  Additional Financial Requirements...
c.  If, in the determination of the Division, the Contractor fails to satisfy any of the requirements for financial soundness set forth in this section or the requirements set forth in Section 5.7 of Appendix A to this Contract, then the Division may, in its discretion...take any other action it deems appropriate, including but not limited to the following: ...
(3)  deny any incentive payments to which the Contractor might otherwise have been entitled under this Contract..."  Massachusetts MH/SAP Contract, Appendix A, pages 82-83.

Corrective action plan

"SECTION 1: ADDITIONAL TERMS AND CONDITIONS
For the purposes of this Contract, the following modifications shall be made to THE COMMONWEALTH  OF MASSACHUSETTS STANDARD SERVICE CONTRACT: ...

3.  SECTION 5: TERMINATION. Insert at the end thereof, the following new subsection:
(g) Corrective Action Plan. Prior to electing to terminate for or without cause, the Division may, but is not required to allow the Contractor to cure any failure by the Contractor to perform or fulfill its obligations under this Contract. If it so elects, the Division shall notify the Contractor in writing by providing a corrective action notice which shall include:
  1. the obligations) the Division believes the Contractor has not performed;
  2. the corrective actions(s) the Division expects the Contractor to take; and
  3. the date or event by which such corrective action(s) shall be completed.

The omission of any instance of non-performance and/or breach in such written corrective action notice shall, in no event, be construed as a waiver of the Division's right to seek or obtain appropriate remedies for any breach or non-performance of this Contract by the Contractor."  Massachusetts MH/SAP Contract, Appendix A, pages 3-4.

"SECTION 5:  REIMBURSEMENT...
C.  Risk Sharing...

5.  Performance Incentives and Sanctions
a.  General Provisions...
  (2)  If the Contractor fails to meet the following performance standards, the Division shall provide written notification to the Contractor.
  (3)  Within 15 business days of the date of the Division's notification of failure to meet a performance standard, the Contractor shall submit a corrective action plan and a timetable for implementation of the corrective action plan to the Division for its review and approval, and any modifications thereto.
  (4)  Subsequent to the Division's review and approval of the corrective action plan and the timetable for its implementation, the Contractor shall implement the corrective action plan within fourteen calendar days."  Massachusetts MH/SAP Contract, Appendix A, pages 36, 41-44.

Liquidated/exemplary damages

"5. Termination…
e) Division's Remedies Upon Termination for Cause or For Emergency...
In addition to and not withstanding the above, Contractor covenants and agrees that, in the events of termination of this Agreement, the Contractor shall pay to the division, as damages,
 (a) such sum as, at the time of termination, the Division reasonably determines that is shall require to compensate a subsequent contractor to complete the delivery of the Services, and
 (b) the sum, reasonably determined by the Division which will compensate the Division for all the direct and indirect cost resulting from the delays in the delivery of the Services upon the Contractor's Default…"  Massachusetts MH/SAP Contract, pages 1-2.

"5.  Performance Incentives and Sanctions...
a.  General Provisions…
(9)  The contractor shall make any payments for performance sanctions owed to the Division within ten (10) business days of receiving a written request for payment from the Division.
(10)  Performance sanctions maybe assessed not withstanding any risk sharing obligations, reconciliation, or any other sanctions or payment obligations that may be imposed pursuant to this contract.
(11)  The maximum amount that may be assessed by the Division as a sanction for each of the performance standards listed below is $200,000 for the first contract Year.  The maximum annual amount that may be assessed by the Division for the performance standards listed below shall be $1,600,000 for the first contract Year…

b.   Performance Standard for Outpatient Visits: ...
(1)  If the annual compliance rate for timeliness of outpatient visits is less than 105% of the baseline but greater than or equal to 100%, the Division may elect to impose a penalty of up to $100,000.
(2)  If the annual compliance rate for timeliness of outpatient visits is less than 95% but not greater than 100% of the baseline,  the Division may elect to impose a penalty of up to $200,000.

c.  Performance Standard for Readmissions: ...
(1)  If the combined inpatient readmission rate exceeds 5% but is less than or equal to 10%, the Division may elect to impose a penalty of up to $100,000.
(2)  If the combined inpatient readmission rate is greater than 10%, the Division may elect to impose a penalty of up to $200,000…" Massachusetts MH/SAP Contract, Appendix A, pages 42-45.

"g.  Performance Standard for Continuation of Care: ...
(1)  If the annual compliance rate for the continuation of care authorization decision and notification process is less than 95% and greater than 90%, the Division may elect to impose a penalty of up to $100,000.
(2)  If the annual compliance rate for the continuation of care authorization decision and notification process is 90% or less, the Division may elect to impose a penalty of up to $200,000...

i.  Performance Standard for Claims Processing: ...
(1)  If the annual compliance rate for claims processing is less than 95% and more than 90%, the Division may elect to impose a penalty of up to $100,000.
(2) If the annual compliance rate for claims processing is 90% or less, the Division may elect to impose a penalty of up to $200,000.

j.  Performance Standard for Report Submission: ...
(1)  If the Division determines that the Contractor is one (1) to seven (7) days late in submitting any such report, the Division may elect to impose a penalty of up to $5,000.
(2)  Thereafter, the Division may elect to impose a penalty of up to $500 for each additional business day after the seventh day following the report's due date until the date on which the report is delivered to the Division..."  Massachusetts MH/SAP Contract, Appendix A, pages 47-49.

"C.  Failure to Perform
1.  In the event that the Contractor is  unable to meet the requirements for administration, delivery and coordination of Covered Services to Enrollees as set forth in this Contract, the Division reserves the right to seek liquidated damages from the Contractor up to a maximum of the sum of the following:  33% of the administrative component of the Capitation Rate for DMA Recipients plus 33% of the Administrative Services Budget for DMH Acute Care Consumers for the Contract Year."  Massachusetts MH/SAP Contract, Appendix A, page 75.

"8.0  REPORTING...
8.01  Same Day Reporting
The Contractor shall provide on a daily basis a report of Critical Incidents for hospitalized Enrollees... Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

8.02  Next Day Reporting
The Contractor shall provide a report of Serious Incidents for Enrollees within 24 hours of such Serious Incident... Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

8.03  Monthly Reporting
The Contractor shall provide, at a minimum, the following reports on a monthly basis  to the Division no later than the 20th day of the immediately following month.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in  Appendix A to this Contract...

8.04  Quarterly Reporting
The Contractor shall deliver quarterly reports regarding the information set forth below, to the Division no later than the 20th day of the month following the end of the quarter.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

8.05  Semi-annual Reporting
The Contractor shall provide semi-annual reports to the Division no later that the 20th day following the end of the semi-annual reporting period designated by the Division.  Failure to meet this deadline for submission of these reports may result in the assessment of financial sanctions as set forth in Appendix A to this Contract...

8.06  Annual Reporting
The Contractor shall provide annual reports to the Division, no later than the 20th day following the end of the annual reporting period established by the Division.  Failure to meet this deadline may result in the assessment of financial sanctions as set forth in Appendix A to this Contract..."  Massachusetts MH/SAP Contract, Appendix B, pages 54-61.

"SECTION 5:  REIMBURSEMENT...
C.  Risk Sharing...

5.  Performance Incentives and Sanctions...
d.  Performance Standard for Timeliness of Inpatient Admissions...
  1)  If the annual compliance rate for timeliness of inpatient admissions is less than 90% and greater than or equal to 80%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate for timeliness of inpatient admissions is less than 80% but greater than 70%, the Division may elect to impose a penalty of up to $200,000...

e.  Performance Standard for Referrals to DMH: ...
  1)  If the annual compliance rate exceeds 95% but is not 100%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate is 90% but less than 95%, the Division may elect to impose a penalty of  up to $200,000...

f.  Performance Standard for Inpatient Prior Approval...
  1)  If the annual compliance rate for the inpatient prior approvals is less than 90%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate for inpatient prior approval is 85% or less, the Division may elect to impose a penalty of up to $200,000...

h.  Performance Standards for Prior Approval of Outpatient Services: ...
  1)  If the annual compliance rate for prior approval and continued care approval decisions and notification for outpatient services is less than 95% and more than 90%, the Division may elect to impose a penalty of up to $100,000.
  2)  If the annual compliance rate for the prior approval and continued care approval decisions and notification for outpatient services is less than 90%, the Division may elect to impose a penalty of up to $200,000..."  Massachusetts MH/SAP Contract, Amendment 1, pages 6-7.

"5.1.1C.5: PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES...
1)  Aftercare Planning:  Disabled Adults...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000...

2)  Family Member/Guardian Involvement:  Children and Adolescents...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000...

3)  Continuing Care:  Children and Adolescents...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000...

4)  Continuing Care:  Adults...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $300,000...

5)  Continuing Care:  Medication Monitoring...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $500,000...

6)  Readmission Rates:  Disabled Adults...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000...

7)  Continuity of Care in Readmission for Children and Adolescents...
  a)  If the actual measure is less than the compliance target, the Division may impose a penalty of up to $300,000...

d.  Penalties Only

1)  Network Procurement...
If letters are not mailed to all applicants by September 26, 1997, the Division may impose a penalty of up to $300,000.

2)  Timely and Adequate Reporting...
If the Contractor fails to comply with this standard, the Division may impose a penalty of up to $5,000 per failure up to a maximum of $300,000.

3)  Provider Quality Forums...
If the Contractor fails to comply with any component of this requirement, the Division may impose a penalty of up to $300,000.

4)  Child/Adolescent Inpatient Access...
If the Contractor fails to comply with this requirement, the Division may impose a penalty of up to $300,000..."  Massachusetts MH/SAP Contract, Amendment 1, pages 14-19.

"Section 5 of Appendix A of the Contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

A.  STANDARDS WITH AN INCENTIVE AND A PENALTY REHABILITATION, RECOVERY, AND EMPOWERMENT

1.  Consumer Satisfaction Teams/Phase II…  These reports must reflect consumer experiences with a minimum of six different providers.

a. If the Contractor does not meet the compliance target, the Division may impose a penalty of up to $200,000...

 2. Self Help/Peer Support…  The compliance targets for this standard shall be: ...
  a) If the contractor does not meet the compliance targets 1,2, and 3 above, the Division may impose a penalty of up to $250,000...

3.  Emergency Service Program (ESP) Training...
  a) If the Contractor does not meet the compliance target, the Division may impose a penalty of up to $100,000...

4.  Dual Diagnosis/Dual Recovery...
  a) If the Contractor does not meet both compliance targets, the Division may impose a penalty of up to $250,000….

SERVICE/SYSTEM INTEGRATION
5.  Medication Monitoring…The initial compliance target for this standard will be 78% of adult mental health discharge events...
  a) If the actual measure is less than 71%, the Division may impose a penalty of up to $350,000.
  b) If the actual measure is less than 74%, but greater than or equal to 71%, the Division may impose a penalty of up to $150,000..

6.  Seven Day Aftercare…The initial compliance target for this standard shall be a rate greater than 80% for such discharges...
  a) If the actual measure is less than 74%, the Division may impose a penalty of up to $300,000.
  b) If the actual measure is greater than or equal to 74%, but less than 77%, the Division may impose a penalty of up to $200,000.
  c) If the actual measure is greater than or equal to 77%, but less than 80%, the Division may impose a penalty of up to $100,000...

PSYCHOPHARMACOLOGY
7.  Medication Protocol for Enhanced Residential Care Program (ERC) Participants...
  a) If the Contractor does not meet the stated compliance targets1,2 and 3 above, the Division may impose a penalty of up to $400,000...

HOMELESSNESS
8.  Discharge Planning...
  a) If the Contractor does not meet the compliance target, the Division may impose a penalty of up to $100,000...

9. Internet Technology and Resources for Services to Homeless Members...
  a) If the Contractor does not meet the compliance targets, the Division may impose a penalty of up to $100,000….

CHILDREN'S SERVICES
10. Enhanced Residential Care (ERC)...
  a) If the Contractor does not meet the compliance target, the Division may impose a penalty of up to $200,000...

11.Community Based Assessments for Certain Children and Adolescents in the Northeast...
  a) If the Contractor does not meet the compliance target, the Division may impose a penalty of up to $200,000...

FAMILIES
12.Preventive Services-Family Support...
  a) If the Contractor does not meet the compliance target, the Division may impose a penalty of up to $200,000…

SUBSTANCE ABUSE SERVICES
13. Payment of LAMM/Methadone Case Rate..
  a) If the Contractor does not meet the compliance targets land 2 above, the Division may impose a penalty of up to $400,000...

OUTCOMES MEASUREMENT
14. Review of Provider Practice...
  a) If the Contractor does not submit the report by May 1, 2000, the Division may impose a penalty of up to $300,000...

C. STANDARDS WITH A PENALTY ONLY
REPORTING
18. Timely and Adequate Reporting...
If the Contractor fails to comply with this standard, the Division may impose a penalty of up to $5,000 per failure to a maximum of $50,000.

PROVIDER FORUMS
19. Provider Quality Forums...
If the Contractor does not convene two such forums and two such workshops by the above dates, the Division may impose a penalty of up to $300,000."   Massachusetts MH/SAP Contract, Amendment 6, pages 2-6.

State payment to out-of plan provider furnishing necessary care, recouped from plan

"5. Termination…
e) Division's Remedies Upon Termination for Cause or For Emergency...
In addition to and not withstanding the above, Contractor covenants and agrees that, in the events of termination of this Agreement, the Contractor shall pay to the division, as damages, (a) such sum as, at the time of termination, the Division reasonably determines that is shall require to compensate a subsequent contractor to complete the delivery of the Services…"  Massachusetts MH/SAP Contract, pages 1-2.

Termination

"5. Termination.  Please reference Appendix A: Scope of Services, Section 1: Additional Terms and Conditions.  This contract shall terminate on the date specified in this Contract, unless extended in compliance with the terms of this contract and all other regulations and requirements of law, or unless terminated under the following conditions: ...

b) For Cause.  If, in the opinion of the Division, the Contractor fails to fulfill his/her obligations, the Division may terminate this Contract by giving written notice to the Contractor at least seven (7) calendar days, before the effective date of termination stated in the notice.  The notice shall state the circumstances of the alleged breach and may state a reasonable period., not less than seven (7) calendar days, during which the alleged breach may be cured, subject to the approval of the Division.  This contract shall be terminated immediately in the event of fraud or program abuse.

c) Emergency.  The Division may terminate or suspend this Contract for up to sixty (60) calendar days by providing written notice to the Contractor stating the grounds for the Division's action in the form of telegram, mailgram, hand-carried letter or other appropriate written means if the Division determines that immediate action is necessary to protect state and or federal funds or property of to protect persons from injury.  Such termination or suspension shall be effective upon receipt of notice or other suspension or termination by the Contractor…"  Massachusetts MH/SAP Contract, pages 1-2.

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of...In the event of Contractor's compliance with the provisions of this section, the Division shall impose such sanctions as it deems appropriate, including, but not limited to...termination or suspension of  this Contract…"  Massachusetts MH/SAP Contract, page 4.

"6.  Additional Financial Requirements...
If, in the determination of the Division, the Contractor fails to satisfy any of the requirements for financial soundness set forth in this section or the requirements set forth in Section 5.7 of Appendix A to this Contract, then the Division may, in its discretion, terminate this Contract..."  Massachusetts MH/SAP Contract, Appendix A, pages 82-83.

Withholding of capitation

"5. Termination...
e) Division's Remedies Upon Termination for Cause Or For Emergency:  Notwithstanding the terms contained in this section in the event of termination, the Contractor shall not be relieved of liability to the Division for injury or damages sustained by the Division by virtue of any breach of this contract by the Contractor.  In the event of termination pursuant to this Section, the Division may withhold any payments to the contractor for the purpose of set off until such time as the exact amount of damages due to the Division from the Contractor is determined…"  Massachusetts MH/SAP Contract, pages 1-2.

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of… In the event of Contractor's compliance with the provisions of this section, the Division shall impose such sanctions as it deems appropriate, including, but not limited to, withholding of payments to the Contractor under this contract until the Contractor complies…"  Massachusetts MH/SAP Contract, page 4.

"4.  Cash Transfers...
K.  In the event that audit findings made pursuant to this Contract of DSRA and/or CCA operation indicate, in the Division's determination, that the Contractor has failed to comply with any provision of this Contract, the Division may elect to impose additional controls on the Contractor's access to the DSRA and /or the CCA, including but not limited to...withholding the administrative component of the Capitation Rate... The Division may impose these...withholds until such time as audit-identified deficiencies are demonstrably corrected..."  Massachusetts MH/SAP Contract, Appendix A, pages 66, 69.

"6.  Additional Financial Requirements...
c.  If, in the determination of the Division, the Contractor fails to satisfy any of the requirements for financial soundness set forth in this section or the requirements set forth in Section 5.7 of Appendix A to this Contract, then the Division may, in its discretion...take any other action it deems appropriate, including but not limited to the following: ...
(1)  withhold some portion of the administrative component of the Capitation Rate…"  Massachusetts MH/SAP Contract, Appendix A, pages 82-83.

Other

"6.  Additional Financial Requirements...
c.  If, in the determination of the Division, the Contractor fails to satisfy any of the requirements for financial soundness set forth in this section or the requirements set forth in Section 5.7 of Appendix A to this Contract, then the Division may, in its discretion...take any other action it deems appropriate, including but not limited to the following: ...
(2)  require changes to the DSRA permitted by Section 5.4.C. of  Appendix A to this Contract...
(4)  exercise any and all rights under the performance bond as set forth in Appendices U and X to this Contract.

C.  Failure to Perform...
2.  In the event that the Division determines that the Contractor fails to meet the requirements for administration, delivery and coordination of Covered Services to Enrollees as set forth in this Contract, the Division  reserves the right to impose additional requirements as set forth in  Section 5.4.D.5. of Appendix A to this Contract.

3.  Notwithstanding any other provisions in this Contract, in the event that the Contractor fails to meet any of the requirements for payment and performance for the administration, delivery and coordination of Covered Services to Enrollees as set forth in this Contract, the Division reserves the right to exercise any and all remedies contained in the Contractor's Performance Bond/Guarantee Certification included as Appendices U and X to this Contract."  Massachusetts MH/SAP Contract, Appendix A, pages 82-84.

Premium includes all covered services

"SECTION 2: DEFINITIONS
The following terms shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise...

Capitation Rate - shall mean a follow amount equal to the sum of the Children and Families Capitation Rate and the Persons with Disabilities Capitation Rate paid by the Division to the Contractor on a per Recipient per month basis for the administration and delivery of mental health and substance abuse services for the Persons with disabilities' and 'Children and Families' groups."  Massachusetts MH/SAP Contract, Appendix A, page 6.

Fee-for-service for some or all covered services

"2.  Notwithstanding the other provision of Section 5.1.3, the parties shall agree to enter into negotiations regarding the Division's compensation to  the Contractor for the cost of actual expenditures for certain new services provided by the Contractor not currently included as Covered Services, and approved by the Division prior to implementation...
Such services may include, but are not limited to, the following:
  a.  Family-Based Services:  incremental claims cost associated with the DSS Family-based initiative;
  b.  Multi-Systemic Therapy:  incremental costs associated with the Contractor's implementation of the Multi-Systemic Therapy initiative of the Annie Case Project;
  c.  Acute Treatment Services Redesign:  costs associated with the Contractor's implementation of the redesign of the detoxification services system; and/or
  d.  Pervasive Developmental Disorders:  costs associated with any modifications made to the Contractor's Medically Necessary Criteria with regard to members with these diagnoses.

The Contractor shall document its costs in providing services pursuant to this Section and submit such documentation to the Division for its review and approval.  The Division shall deposit into the DSRA the amount which, in its determination, represents the incremental costs of any initiative approved by the Decision under this subsection…"  Massachusetts MN/SAP Contract, Amendment 5, pages 9-10.

Withholding of payments

"5. Termination...
e) Division's Remedies Upon Termination for Cause Or For Emergency:  Notwithstanding the terms contained in this section in the event of termination, the Contractor shall not be relieved of liability to the Division for injury or damages sustained by the Division by virtue of any breach of this contract by the Contractor.  In the event of termination pursuant to this Section, the Division may withhold any payments to the contractor for the purpose of set off until such time as the exact amount of damages due to the Division from the Contractor is determined…"  Massachusetts MH/SAP Contract, pages 1-2.

"18. Non-Discrimination in Employment and Affirmative Action.  The Contractor shall not discriminate against any qualified employee or applicant for employment because of… In the event of Contractor's compliance with the provisions of this section, the Division shall impose such sanctions as it deems appropriate, including, but not limited to, withholding of payments to the Contractor under this contract until the Contractor complies…"  Massachusetts MH/SAP Contract, page 4.

"4.  Cash Transfers...
K.   In the event that audit findings made pursuant to this Contract of DSRA and/or CCA operation indicate, in the Division's determination, that the Contractor has failed to comply with any provision of this Contract, the Division may elect to impose additional controls on the Contractor's access to the DSRA and /or the CCA, including but not limited to... withholding the administrative component of the Captivation Rate; and withholding incentive payments and bonuses. The Division may impose these... withholds until such time as audit-identified deficiencies are demonstrably corrected..."  Massachusetts MH/SAP Contract, Appendix A, pages 66, 69.

"6.  Additional Financial Requirements...
c.  If, in the determination of the Division, the Contractor fails to satisfy any of the requirements for financial soundness set forth in this section or the requirements set forth in Section 5.7 of Appendix A to this Contract, then the Division may, in its discretion...take any other action it deems appropriate, including but not limited to the following: ...
(1)  withhold some portion of the administrative component of the Capitation Rate...
(3) deny any incentive payments to which the Contractor might otherwise have been entitled under this contract..."  Massachusetts MH/SAP Contract, Appendix A, pages 82-83.

State delegation of third party liability collection

"5.2  Reimbursement Methodology for DMH Acute Care Consumers...
B.  Reimbursement Rules for Designated Emergency Programs (DEPs)/Emergency Screening Programs (ESPs)
1.  In accordance with Section 5.2 A of Appendix A to this Contract, the Contractor shall utilize DMH Service Compensation Payments to pay ESPs/DEPS, whichever is applicable, for Covered Services rendered to DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements:
 a.  The Contractor shall require ESPs/DEPs to identify and bill all available sources of Third Party Liability (TPL) for DMH Acute Care Consumers who are not Recipients or Excluded Recipients...

C.  Reimbursement Rules for DMH Covered Services for DMH Acute Care Consumers
1.  In accordance with Section 5.2.A of this Appendix A to the Contract, the Contractor shall utilize DMH Service Compensation Rate Payments to reimburse Network Providers and non-Network providers for DMH Covered Services as described in Appendix C to this Contract for DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements:
 a.  For DMH Covered Services rendered to DMH Acute Care Consumers who are not Recipients, the Contractor shall require Network Providers and non-Network providers to bill TPL, the Free Care Pool in accordance with applicable law..."  Massachusetts MH/SAP Contract, Appendix A, pages 56-61.

"l0.0  BENEFIT COORDINATION - RECIPIENTS
The Contractor shall:
10.01.01  Develop a plan to be submitted to the Division for prior review and approval, no later than the end of the sixth month of the first Contract Year, which shall address systems and resources required to perform Benefit Coordination for Recipients (‘Recipient Benefit Coordination Plan'). The Recipient Benefit Coordination Plan shall address and propose resolution to the following two major Benefit Coordination situations that arise when Recipients receiving a service(s) are:
  a.  subsequently granted retroactive eligibility for TPL; and
  b. determined to have TPL by the Contractor or Provider at the time the service(s) were delivered.

10.01.02  Ensure that the Recipient Benefit Coordination Plan, at a minimum, addresses the process for identifying and recovering inappropriately paid funds, describes the tracking and reporting mechanisms, and the processes and procedures to inform the Division of TPL.

10.01.03  Develop a plan to be submitted to the Division for prior review and approval no later than the sixth month of the first Contract Year which shall outline the policies and procedures to be implemented by the Contractor to notify the Division when the Contractor has identified a Recipient with TPL.

11.0  BENEFIT COORDINATION - DMH ACUTE CARE CONSUMERS
The Contractor shall:

11.01.01  Establish and implement a Benefit Coordination plan for DMH Acute Care Consumers ('DMH Benefit Coordination Plan') which shall be effective on the Full Service Start Date; be reviewed and approved by the Division; and address systems and resources required to perform the following activities: ...
  b.  provide training and ongoing support to the ESPs or, in the alternative, the DEPs, whichever is applicable, to maximize TPL available to cover DMH Acute Care Consumers (Medicaid, Medicare, or other health insurance)..."  Massachusetts MH/SAP Contract,  Appendix B, pages 72-73.

Actuarial sound capitation rates

"SECTION 2: DEFINITIONS
The following term shall have the meaning stated, as they appear hereunder, unless the context clearly indicates otherwise…

Upper Payment Limit (UPL) - the maximum amount, calculated by the Commonwealth according to federal requirements under 42 CFR 447.361 which may be paid under the Contract.  This amount shall not exceed the cost to the Division of providing the same services under this Contract, on a fee-for-service, to an actuarially equivalent non-enrolled population."  Massachusetts MH/SAP Contract, Appendix A, pages 6, 16.

Time lines for payment to network providers

"i.  Performance Standard for Claims Processing:  The Contractor shall review, process, and remit a check for Clean Claims submitted to  the Contractor by the Provider within thirty days of receipt of the Clean Claims..."   Massachusetts MH/SAP Contract, Appendix A, page 52.

"2.05  Provider Reimbursement
The Contractor shall: ...
2.05.04  Reimburse all Clean Claims submitted by Providers for all services authorized by the Contractor within thirty days of receipt of the Clean Claim."   Massachusetts MH/SAP Contract, Appendix B, page 17.

Special payments for certain classes of providers

"B. Reimbursement Rules for Designated Emergency Programs (DEPs) / Emergency Screening Programs (ESPs)
1. In accordance with Section 5.2 A of Appendix A to this Contract, the Contractor shall utilize DMH Service Compensation Payments to pay ESPs/DEPS, whichever is-applicable, for Covered Services rendered to DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements: ...
  b. The Contractor shall reimburse ESPs/DEPs for the cost of services rendered to those DMH Acute Care Consumers who have TPL whether or not their TPL benefits have been exhausted in an amount not to exceed the difference between the applicable ESP/DEP reimbursement rate as negotiated by the Contractor and TPL receivable, if any...
  d. The Contractor shall utilize DMH Compensation Rate Payments to reimburse ESPs/DEPs in an amount not to exceed applicable reimbursement rates as approved by the Division only for services rendered to DMH Acute Care Consumers without TPL, even if benefits have been exhausted, and only to the extent the costs of services exceed any and all sliding fee scale receivables...

C.  Reimbursement Rules for DMH Covered Services for DMH Acute Care Consumers
1. In accordance with Section 5.2.A of this Appendix A to the Contract, the Contractor shall utilize DMH Service Compensation Rate Payments to reimburse Network Providers and non-Network providers for DMH Covered Services as described in Appendix C to this Contract for DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements:

  a. For DMH Covered Services rendered to DMH Acute Care Consumers who are not Recipients, the Contractor shall require Network Providers and non-Network providers to bill TPL, the Free Care Pool in accordance with applicable law, and DMH Acute Care Consumers according to a sliding fee scale. By July 1, 1996, the Contractor shall submit for the Division's review and approval a sliding fee scale in accordance with this section...
  c. The Contractor shall not reimburse Network Providers and non-Network providers for DMH Covered Services to any DMH Acute Care Consumer with TPL; whether or not the DMH Acute Care Consumer's TPL benefits have been exhausted.
  d. The Contractor shall utilize DMH Service Compensation Rate Payments to reimburse Network Providers and non-Network providers in an amount not to exceed applicable Provider reimbursement rates as approved by the Division only for DMH Covered Services rendered to DMH Acute Care Consumers without TPL, even if benefits have been exhausted, and only to the extent the costs of DMH Covered Services exceed any and all Free Care Pool and/or sliding fee scale receivables...
  f. The Contractor shall require Network Providers and non-Network providers to apply any uncollectible self-pay receivables to bad debt and to bill the Free Care Pool if in accordance with applicable law."  Massachusetts MH/SAP Contract, Appendix A, pages 53-55.

"Section 5.6:  Free Care Reimbursement to Former Replacement Units...
(b)  Payments made by the Contractor to the Selected RUs pursuant Free Care Agreements shall be funded from the Service Compensation Rate for DMH Covered Services detailed in Section 5.2 of Appendix A to the Contract; provided, further, that the Contractor shall not be responsible in any manner for payment of any claims submitted by Selected RUs for services provided pursuant to a Free Care Agreement in excess of the Service Compensation Rate payments paid to the Contractor..."  Massachusetts MH/SAP Contract, Amendment 1, pages 21-22.

"F. Performance Incentives, Penalties, and Initiatives...
4. Section 5.2.AA.1. shall be amended by adding at the end thereof the following new Section 5.2.AA.l.d.:

Section 5.2.AA.l.d.: For the fourth Contract Year, the portion of the Compensation Rate payments used to reimburse providers of Inpatient Mental Health Services and Observation/Holding Beds to Group B DMH Acute Care Consumers and Group C Acute Care Consumers, combined, does not exceed the amount of $2,768,808; provided, however, that in the event that the Contractor's expenditures for Group B DMH Acute Care Consumers for Inpatient Mental Health Services and Observation/Holding Beds exceeds $2,768,808 in FY 00, the Contractor shall be reimbursed for said expenditures."  Massachusetts MH/SAP Contract, Amendment 5, pages 9-10.

"BENEFIT ADVOCACY
15. Homeless Shelters and Detoxification Facilities...
The Contractor shall reimburse participating shelters and detoxification facilities a $30 per application incentive, and shall receive an amount equal to 15% of each $30 application incentive paid."  Massachusetts MH/SAP Contract, Amendment 6, page 9.

Payment rules for non-network providers

"2.05  Provider Reimbursement...
2.05.07  Reimburse non-Network hospital providers as follows, when they provide mental health and/or substance abuse Emergency Services:

a.  payment for acute inpatient hospital mental health services shall be made at the Medicaid all-inclusive psychiatric per diem rate for psychiatric admissions as set by the Division from time-to-time in accordance with the non-Network provider's agreement with the  Division, pursuant to the Division's Acute Hospital Request for Application (RFA) in effect at that time, if such an agreement exists, and subject to certain limitations in the case of transfers, as set forth in the RFA;
b.  payment for acute inpatient hospital substance abuse services shall be made at the Division's transfer per-diem rates capped at the per discharge payment, as set by the Division pursuant to the RFA in effect at that time, if such an agreement exists; and
c.  payment for acute hospital outpatient department mental health or substance abuse services shall be made at rates set by the Division pursuant to the RFA in effect at that time, if such an agreement exists."  Massachusetts MH/SAP Contract, Appendix B, pages 17-19.

Cost sharing

"B. Delegation to Subcontractors
The Contractor shall: ...

4. include the following language in all Provider Agreements, agreements with non-Network providers and other agreements with providers:
'Providers shall not seek or accept any payment from any Recipient for any Covered Services rendered, nor shall providers have any claim against, or seek any payment from the Division. Instead, providers shall look solely to the Partnership for payment with respect to Covered Services rendered to Recipients. Furthermore, providers shall not maintain any action at law or in equity against any Recipient or the Division to collect any sums that are owed by the Partnership under this Agreement, for any reason, even in the event that the Partnership fails to pay, becomes insolvent or otherwise breaches the terms and conditions of this Agreement. This Section shall survive termination of this Agreement' (where 'Agreement' shall refer to the agreement between the Contractor and any subcontractor and where 'provider' shall refer to the subcontractor, including Network and non-Network providers, with whom the Contractor is contracting,)…"  Massachusetts MH/SAP Contract, Appendix A, pages 18-19.