Current through Register Vol. 50, No. 9, September 20, 2024
A. The MCO
agrees to be subject to intermediate sanctions and other measures to obtain
compliance with the terms and conditions of the contract.
1. The specific grounds for intermediate
sanctions and other measures to obtain compliance shall be set forth within the
contract.
2. The determination of
noncompliance is at the sole discretion of the department.
3. It shall be at the departments sole
discretion as to the proper recourse to obtain compliance.
B. Intermediate Sanctions
1. The department may impose intermediate
sanctions on the MCO if the department finds that the MCO acts or fails to act
as specified in
42 CFR
§438.700 et seq., or if the department finds
any other actions/occurrences of misconduct subject to intermediate sanctions
as specified in the contract.
2.
The types of intermediate sanctions that the department may impose shall be in
accordance with §1932 of the Social Security Act (42
U.S.C. §1396u-2) and
42 CFR
§438.700 et seq.
3. The department will provide the MCO with
due process in accordance with
42 CFR
438.700 et seq., including timely written
notice of sanction and pre-termination hearing.
4. The department will give the CMS Regional
Office written notice whenever it imposes or lifts a sanction for one of the
violations listed in
42 CFR
§438.700 et seq., specifying the affected
MCO, the kind of sanction, and the reason for the departments decision to lift
a sanction.
C. Other
Measures. In addition to intermediate sanctions, the department may impose
other measures to obtain MCO compliance with the terms and conditions of the
contract, including but not limited to administrative actions, corrective
action plans, and/or monetary penalties as specified in the contract.
1. Administrative actions exclude monetary
penalties, corrective action plans, intermediate sanctions, and termination,
and include but are not limited to a warning through written notice or
consultation and education regarding program policies and procedures.
2. The MCO may be required to submit a
corrective action plan (CAP) to the department within the timeframe specified
by the department. The CAP, which is subject to approval or disapproval by the
department, shall include:
a. steps to be
taken by the MCO to obtain compliance with the terms of the contract;
b. a timeframe for anticipated compliance;
and
c. a date for the correction of
the occurrence identified by the department.
3. The department, as specified in the
contract, has the right to enforce monetary penalties against the MCO for
certain conduct, including but not limited to failure to meet the terms of a
CAP.
4. Monetary penalties will
continue until satisfactory correction of an occurrence of noncompliance has
been made as determined by the department.
D. Any and all monies collected as a result
of monetary penalties or intermediate sanctions against a MCO or any of its
subcontractors, or any recoupment(s)/repayment(s) received from the MCO or any
of its subcontractors, shall be placed into the Louisiana Medical Assistance
Trust Fund established by
R.S.
46:2623.
E. Termination for Cause
1. Issuance of Notice Termination
a. The department may terminate the contract
with an MCO when it determines the MCO has failed to perform, or violates,
substantive terms of the contract or fails to meet applicable requirements in
§§1903(m), 1905(t) or 1932 of the Social Security Act in accordance with the
provisions of the contract.
b. The
department will provide the MCO with a timely written Notice of Intent to
Terminate notice. In accordance with federal regulations, the notice will
state:
i. the nature and basis of the
sanction;
ii. pre-termination
hearing and dispute resolution conference rights, if applicable; and
iii. the time and place of the
hearing.
c. The
termination will be effective no less than 30 calendar days from the date of
the notice.
d. The MCO may, at the
discretion of the department, be allowed to correct the deficiencies within 30
calendar days of the date that the notice was issued, unless other provisions
in this Section demand otherwise, prior to the issue of a notice of
termination.
F
. Termination due to Serious Threat to Health of Members
1. The department may terminate the contract
immediately if it is determined that actions by the MCO or its subcontractor(s)
pose a serious threat to the health of members enrolled in the MCO.
2. The MCO members will be enrolled in
another MCO.
G .
Termination for Insolvency, Bankruptcy, Instability of Funds. The MCOs
insolvency or the filing of a bankruptcy petition by or against the MCO shall
constitute grounds for termination for cause.
H. Termination for Ownership Violations
1. The MCO is subject to termination unless
the MCO can demonstrate changes of ownership or control when a person with a
direct or indirect ownership interest in the MCO (as defined in the contract
and PE-50) has:
a. been convicted of a
criminal offense as cited in §1128(a), (b)(1) or (b)(3) of the Social Security
Act, in accordance with federal regulations;
b. had civil monetary penalties or assessment
imposed under §1128(A) of the Social Security Act; or
c. been excluded from participation in
Medicare or any state health care program.
I. MCO Requirements Prior to Termination for
Cause. The MCO shall comply with all of the terms and conditions stipulated in
the contract and department issued guides during the period prior to the
effective date of termination. The MCO is required to meet the requirements as
specified in the contract if terminated for cause.
J. Termination for Failure to Accept Revised
Monthly Capitation Rate. Should the MCO refuse to accept a revised monthly
capitation rate as provided in the contract, the MCO may provide written notice
to the department requesting that the contract be terminated effective at least
60 calendar days from the date the department receives the written request. The
department shall have sole discretion to approve or deny the request for
termination, and to impose such conditions on the granting of an approval as it
may deem appropriate, but it shall not unreasonably withhold its approval.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
