Medicaid Managed Care Organization Hospital Access Program (MCO-HAP) Region 4, 5 or 6 Document Index

Transcription

1 Medicaid Managed Care Organization Hospital Access Program (MCO-HAP) Region 4, 5 or 6 Document Index 1. IHA-Hospital Payee Designation Agreement 2. Primary MCO-HAP Hospital Contact Information Sheet 3. Aetna Better Health 4. Blue Cross Blue Shield of Illinois MCO-HAP Hospital Participation Agreement 5. Health Spring of Illinois 6. Community Care Alliance (CCAI) Hospital Participation Agreement 7. Humana Health Plan 8. Illinicare Health 9. Meridian Health Plan Scan and return the signed Hospital Participation Agreements (even if you designate a payee other than IHA), the IHA-Hospital Payee Designation Agreement and the MCO-HAP Hospital Contact Sheet via to MCOHAP@ihastaff.org as soon as possible, but no later than Sept. 12, NOTE: If a hospital does not return the above agreements to IHA by Sept. 12, 2014, IHA will assume that the hospital is making arrangements directly with the MCOs related to the relevant access payments.

2 Hospital Designation of Illinois Hospital Association as Intermediary Payee Under Managed Care Organization Hospital Access Program WHEREAS, by enacting Public Act (the Act ), the Illinois General Assembly has determined that in order to assure continued access to hospital services that a portion of the access payments for hospitals, including those authorized under Article V-A of the Public Aid Code, shall be used to increase the capitation rates paid to Managed Care Organization ( MCOs ) for the purpose of increasing payments by MCOs for hospital services (the Enhanced Capitation ), beginning in state fiscal year 2015; and WHEREAS, the purpose of the Managed Care Organization Hospital Access Program ( Program ) is for MCOs to provide payments (the MCO Hospital Access Payments ) to hospitals to assure access to hospital care to Medicaid beneficiaries in furtherance of the goals of the State of Illinois to assure access to hospital services for Medicaid beneficiaries; and WHEREAS, the undersigned hospital ( Hospital ) has executed a Hospital Participation Agreement with one or more MCOs pursuant to which each MCO has agreed to pay Hospital the MCO Hospital Access Payments as calculated in the Hospital Participation Agreement. Each Hospital Participation Agreement between Hospital and individual MCOs has been provided to IHA by the Hospital and are referred to collectively as the Hospital Participation Agreements. (1) NOW THEREFORE, effective as of the date executed on behalf of Hospital below, Hospital hereby designates the Illinois Hospital Association ( IHA ), an Illinois Not-For-Profit Corporation located at 1151 East Warrenville Road, Naperville, Illinois, and IHA hereby agrees to serve as the intermediary payee for the MCO Hospital Access Payments paid to Hospital by each individual MCO according to the terms of the Program s Hospital Participation Agreements. IHA agrees to abide by the terms of the Hospital Participation Agreements to the same extent as the Hospital with regard to its obligations under such agreements. (2) IHA will maintain one or more bank accounts for the purpose of receiving MCO Hospital Access Payments from MCOs pursuant to the Hospital Participation Agreements and this Designation. IHA will provide Hospital with the information and documents necessary for Hospital to instruct each MCO how to deposit MCO Hospital Access Payments owed to Hospital under the Hospital Participation Agreements into the appropriate bank account. Hospital will provide IHA the information needed by IHA to transfer the aggregate of such MCO Hospital Access Payments to Hospital each month. (3) The parties agree and acknowledge that, upon receipt by IHA, funds transferred to IHA by MCOs under the Program do not become the property of IHA and such funds do not constitute income to IHA. (4) Within four (4) business days of receipt by IHA from MCOs on behalf of Hospital, IHA will transfer the following to Hospital, pursuant to Hospital s instructions and the Hospital Participation Agreements: (a) MCO Hospital Access Payments received by IHA from MCOs on behalf of Hospital and available for transfer as of that date and (b) any penalties for late MCO-HAP IHA-Hospital Payee Designation Agrt. (8/22/14) 1

3 payments received by IHA from MCOs on behalf of Hospital and available for transfer as of that date. (5) In the event that one or more MCOs fails to deposit MCO Hospital Access Payments owed to Hospital by the date such payment is due pursuant to the Hospital Participation Agreement with Hospital, IHA shall make the transfer to Hospital described in Paragraph 3 based upon the amounts on deposit and available for transfer. Any deposits subsequently received from MCOs by IHA will be transferred to Hospital within five (5) business days of receipt by IHA from MCOs on behalf of Hospital. (6) The obligation of each MCO to pay Hospital Access Payments to Hospital and the terms and conditions of such payments are governed by relevant State law and the relevant Hospital Participation Agreements between Hospital and individual MCOs. IHA has no obligation to make any payments or transfers to Hospital other than from funds transferred to IHA by MCOs for the specific purpose of paying Hospital pursuant to the Hospital Participation Agreements. IHA has no obligation to enforce any Hospital Participation Agreement on behalf of Hospital or to attempt collection of any amounts owed by MCOs to Hospital. In the absence of adequate funds transferred by one or more MCOs to make payments to Hospital pursuant to the Hospital Participation Agreements, IHA will not make payments or transfers to Hospital using funds received on behalf of other hospitals participating in the Program. (7) Hospital hereby agrees to pay IHA an annual administrative fee for performing its obligations under this Designation. IHA s annual costs are estimated at $300,000 and each participating hospital will pay a flat fee reflecting its share of those costs based on the proportion of the payments it receives under the hospital assessment program, as compared to the total of all such payments for all hospitals. Thus, the amount of the annual administrative fee shall be calculated as follows: ($300,000) * (Hospital s Access Payments under Sections 5A-12.2 and 5A-12.4 of the Public Aid Code/Total Access Payments under Sections 5A-12.2 and 5A-12.4 of the Public Aid Code for all hospitals). In addition to the above administrative fee, if Hospital requires the amounts to be paid to it under this Designation to be transmitted via a wire transfer, as opposed to an automated clearinghouse transaction, any related bank fees shall be the responsibility of Hospital. IHA may deduct the amount of the administrative fee and any wire transfer fees from one or more transfers under Paragraph 3. (8) This Designation shall take effect on the date it is executed on behalf of Hospital and shall continue in effect as long as the Program is in effect, unless terminated by operation of law or by either party with the provision of at least 60 days written notice to the other party. (9) This Designation constitutes the entire understanding between the parties with respect to this subject matter. Neither party may assign this Designation without the prior written consent of the other party. Any notices required under this Designation shall be provided in writing to the chief executive officer of each party, unless a party has provided a written designation of another representative to receive such notices. This Designation may only be amended in writing signed by both parties. MCO-HAP IHA-Hospital Payee Designation Agrt. (8/22/14) 2

4 (10) This Designation may be executed in one or more counterparts, each of which counterpart shall be an original. Delivery of an executed counterpart of this Designation by facsimile or electronic transmission in a Portable Document Format ( PDF ) shall be equally effective as manual or mail delivery. Each counterpart, whether delivered manually, by mail, by facsimile or PDF, or by other electronic transmission, shall be deemed an original. IN WITNESS WHEREOF, the parties have executed this Designation effective as of the date executed on behalf of Hospital below. Hospital Illinois Hospital Association Name: City: By: By: Print: Print: Maryjane A. Wurth Title: Title: President and CEO Date: Date: August 22, 2014 MCO-HAP IHA-Hospital Payee Designation Agrt. (8/22/14) 3

5 MCO-HAP Contact Information 1. Are you providing an MCO-HAP contact for a hospital or a system? Hospital System 2. Please enter the name of your hospital/system below: 3. Enter the MCO-HAP specific contact information below: Name Title Address City/Town Zip Code Phone Number Address CC Address (utilize for an assistant)

6 Managed Care Organization Hospital Access Program Hospital Participation Agreement The undersigned hospital ( Hospital ) and the undersigned Medicaid Managed Care Organization ( MCO ) hereby agree to participate in the Managed Care Organization Hospital Access Program (the Program ) as of September 1, 2014, as follows: WHEREAS, the Illinois General Assembly has determined and authorized certain payments to preserve and improve access to hospital services for Medicaid beneficiaries, including those hospital access payments authorized under Sections 12.2 and 12.4 of Article V-A of the Illinois Public Aid Code ( Article V-A Hospital Access Payments ); and WHEREAS, the Illinois General Assembly has determined that at least 50% of Medicaid beneficiaries are to be enrolled in risk based care coordination or managed care programs by January 1, 2015; and WHEREAS, the Illinois General Assembly has articulated the importance of, and requested the cooperation of hospitals and the MCOs in preserving predictable sources of revenue to the state, including the federal funds generated through the Hospital Assessment Program, in order to preserve and assure access to hospital and other health care services for Medicaid beneficiaries as the Illinois Medicaid program increases the enrollment of beneficiaries in capitated managed care arrangements; and WHEREAS, the Illinois General Assembly has determined pursuant to the enactment of Public Act as enacted on June 16, 2014 (the Act ), that in order to assure continued access to hospital services that a portion of the access payments for hospitals, including those authorized under Article V-A of the Public Aid Code, shall be used to increase the capitation rates paid to MCOs for the purpose of increasing payments by MCOs for hospital services beginning in state fiscal year 2015; and WHEREAS, the purpose of the Program is for MCOs to provide payment (the MCO Hospital Access Payment ) to hospitals to assure access to hospital care to Medicaid beneficiaries in furtherance of the goals of the State of Illinois, as articulated by the General Assembly, to assure access to hospital services for Medicaid beneficiaries; and WHEREAS, each MCO receives specified monthly capitation rates (for purposes of the Program, such increased capitation rates are referred to as Enhanced Capitation ) from the Illinois Department of Healthcare and Family Services ( HFS ) specifically designated to be exclusively used by the MCOs to make the MCOs payments to hospitals as required by the Act and, in doing so, preserve and improve access to hospital services for Medicaid beneficiaries; and 1 Aetna

7 WHEREAS, the Illinois Hospital Association ( IHA ) has agreed to help administer the Program and to receive payments from the MCOs on behalf of the hospitals that have designated IHA to do so by entering into a Hospital Participation Agreement with the MCO (the Participating Hospitals ); and WHEREAS, the MCO has determined that this Program would most effectively achieve the goals of the State of Illinois, as articulated by the Illinois General Assembly, to assure access to hospital services for Medicaid beneficiaries. NOW, THEREFORE, in consideration of the mutual covenants and conditions hereinafter set forth and other good and valuable consideration, the receipt of which is hereby acknowledged, the parties agree as follows: Definitions. For purposes of this Agreement, the following terms will have the definitions ascribed to them below. Access Payment means the monthly payment made by MCO to IHA or Hospital (see Section 2) based on the methodology described in Paragraph 4 of this Agreement. Article V-A Hospital Access Inpatient Payment Percentage means a fraction where: the numerator of which is the Article V-A Hospital Access Payments attributable to inpatient services for state fiscal year 2014 for Hospital; and the denominator of which is the Article V-A Hospital Access Payments attributable to inpatient services for state fiscal year 2014 for all hospitals in Hospital s HFS managed care region. Article V-A Hospital Access Outpatient Payment Percentage means a fraction where: the numerator of which is the Article V-A Hospital Access Payments attributable to outpatient services for the state fiscal year 2014 for a hospital; and the denominator of which is the Article V-A Hospital Access Payments attributable to outpatient services for state fiscal year 2014 for all hospitals in Hospital s HFS managed care region. Enhanced Capitation means that portion of MCO s capitation payment received from HFS specifically attributable to the Access Payments as authorized under Sections 5A-12.2(s) and (t) of the Illinois Public Aid Code. Existing Provider Contract means any contract between MCO and Hospital under which Hospital provides health care services to MCO s enrollees in exchange for reimbursement from MCO. HFS means the Illinois Department of Healthcare and Family Services or its successor. Hospital means the undersigned hospital, a hospital facility participating in the Illinois Medicaid program. 2 Aetna

8 IHA means the Illinois Hospital Association. MCO means the undersigned managed care organization, an entity providing Medicaid benefits to beneficiaries under a contract with HFS. MCO Hospital Access Inpatient Payment means the product determined by multiplying the MCO s total Enhanced Capitation attributable to inpatient hospital services by Hospital s Article V-A Hospital Access Inpatient Payment Percentage. MCO Hospital Access Outpatient Payment means the product determined by multiplying the MCO s total Enhanced Capitation attributable to hospital outpatient services by Hospital s Article V-A Hospital Access Outpatient Payment Percentage. 1. Access Payments. MCO agrees to pay Access Payments to Hospital or its designated payee (see paragraph 2) on a monthly schedule. MCO s payment of Access Payments is expressly conditioned on MCO s receipt of Enhanced Capitation from HFS. The Parties agree that the Access Payments are for the purpose of ensuring continued access to hospital services for Illinois Medicaid beneficiaries. Access Payments do not replace or supplant any other amounts paid or payable to Hospital by MCO under any Existing Provider Contracts. 2. Hospital designates IHA to serve as its payee to receive payments under the Program from the MCO and directs the MCO to make such payments to IHA. To designate a Payee other than IHA, complete this paragraph: Notwithstanding any other provision in this agreement, to reject the above designation of IHA as its payee to receive payments under this agreement from MCO, Hospital must initial here:. Hospital directs the MCO to make payments under this agreement to {insert Hospital or other designated payee}. By selecting a payee other than IHA, Hospital agrees that IHA has no responsibility related to the issuance of payments to the Hospital under this agreement. Such election may also be revoked only by written notice to MCO. If Hospital utilizes IHA as its payee, MCO s liability for any given Access Payment is discharged in its entirety upon issuance of payment to IHA in accordance with this Agreement. If Hospital elects to maintain IHA as the default payee, Hospital agrees that any contract it enters into with IHA regarding the Access Payments will contain terms that require IHA to abide by the terms of this Agreement to the same extent as Hospital with regard to its obligations hereunder. 3 Aetna

9 3. Each month, HFS will publish an Enhanced Capitation Rate Report. The report will, at a minimum, provide the per member, per month Enhanced Capitation amount attributable to each plan; the proportion of the Enhanced Capitation attributable to inpatient and outpatient hospital services; the number of enrollees for which the Enhanced Capitation is being paid; and the total Enhanced Capitation for that month. Upon receipt of the Enhanced Capitation Rate Report and the Enhanced Capitation amount the MCO shall, by the 24 th of each month or within three (3) business days of receiving the Enhanced Capitation Rate Report (whichever is later), review and notify IHA and HFS of any disagreements it has with the Enhanced Capitation Rate Report. 4. The IHA will be responsible for calculating the amount of the Access Payment payable by MCO to Hospital or its designated payee using the Enhanced Capitation Rate Report. The MCO will distribute the Access Payments to Hospital in a manner that replicates the distribution of hospital access payments under Article V-A of the Public Aid Code. Therefore, upon receipt of the Enhanced Capitation Rate Report and the Enhanced Capitation amount IHA shall by the 26 th of each month or within five (5) business days of receiving the Enhanced Capitation Rate Report, whichever is later, verify and notify in writing the chief executive officer of the MCO or his or her designee of the Hospital s payment from the Enhanced Capitation (the MCO Hospital Access Payment ) which shall consist of the sum of the MCO Hospital Access Inpatient Payment and the MCO Hospital Access Outpatient Payment as calculated for that given month. 5. Within four (4) business days (except for the transfer month of February in which transfer shall occur no later than the third (3 rd ) business day of the month), of notification by IHA of the correct Access Payment amount, the MCO shall transfer to the account designated by the Hospital or its designated payee, the MCO Hospital Access Payment owed to the Hospital, as identified under paragraph 4. In the event MCO has a disagreement with respect to a portion of the Enhanced Capitation amount, the MCO shall not delay the issuance of the MCO Hospital Access Payment to the Hospital with respect to any undisputed portion of the Enhanced Capitation amount and shall inform the Hospital or its designated payee of the basis for any adjustment to the MCO Hospital Access Payment. In no event shall MCO be obligated to make more in total MCO Hospital Access Payments than the undisputed Enhanced Capitation amount it has received. In the event the undisputed Enhanced Capitation amount for a given month is insufficient for MCO to pay the entirety of the Access Payments as calculated by IHA for each Hospital, the Access Payment shall be reduced by an amount proportional to the aggregate deficiency in the Enhanced Capitation. MCO shall not be obligated to make the remainder of the Access Payment until such time as the dispute is resolved or MCO has received the entirety of the scheduled Enhanced Capitation for that month. 6. Notwithstanding the foregoing, in no circumstances will MCO be required to pay the Access Payment until at least seven (7) business days following MCO s actual receipt of the Enhanced Capitation for the given month. By way of example, if MCO does not receive the Enhanced Capitation until the fourth business day following IHA notifying 4 Aetna

10 MCO of the Access Payment amount, MCO will not be required to make the Access Payment until the eleventh business day following such notification. 7. The MCO agrees as follows: a. The MCO agrees to provide, within 10 days of receipt of a written request by the Hospital, a separate accounting of its Enhanced Capitation describing in detail the receipt by region and expenditure by hospital of all such Enhanced Capitation. Nothing in this section requires either Party to maintain a separate account with a financial institution specifically for the holding of funds paid under this Agreement. b. The MCO shall procure a surety bond in an amount determined by HFS to approximate one month s liability of its Enhanced Capitation authorized under Section 5A-12.2(s) of the Illinois Public Aid Code. c. Late Payments; Interest. In the event that MCO does not make the Access Payment to Hospital or its designated payee within the timeframes described above, MCO shall pay interest on any past due amounts at the rate of 9% per annum. In the event that the rate of 9% per annum exceeds the maximum rate permissible by law, MCO shall pay the maximum rate of interest otherwise allowed by law. 8. Nothing in the Program shall be construed or used by the MCO or Hospital as justification for seeking changes to its provider agreement with hospitals. Nothing in this Agreement is intended to modify any Existing Provider Contracts between the Parties. 9. The Program shall be in effect beginning in state fiscal year 2015 and shall continue as long as it is authorized under Illinois law. This agreement shall continue as long as the Program is in effect, unless terminated by the Hospital or the MCO or as required by law. Any party may terminate this agreement by providing at least sixty (60) days prior written notice to the other party. 10. This agreement constitutes the entire understanding between the parties with respect to this subject matter. No party may assign this agreement to another party without the prior written consent of the other parties, which consent shall not be unreasonably withheld. Any notices required under this agreement shall be given in writing to the chief executive officer of each party, unless a party has provided a written designation of another representative to receive such notices. This Agreement may only be amended in writing signed by both Parties. 11. This agreement may be executed in two or more counterparts, each of which shall be deemed an original, but all of which shall constitute one and the same instrument. Delivery of an executed counterpart of this Agreement by facsimile or electronic transmission in a Portable Document Format ( PDF ) shall be equally effective as 5 Aetna

11 manual or mail delivery. Each counterpart, whether delivered manually, by mail, by facsimile or PDF, or by other electronic transmission, shall be deemed an original. 12. Disputes. The Parties agree to negotiate in good faith in order to address discrepancies in the amount of the Access Payments. In the event that a dispute cannot be resolved through good faith negotiation, the Parties agree to submit the dispute to arbitration under the Commercial Arbitration Rules of the American Arbitration Association as the exclusive means of resolving the dispute. Judgment on the award rendered in any such arbitration may be entered in any court of competent jurisdiction. 13. Except as is otherwise specifically provided in this Agreement, the parties have not created and do not intend to create by this Agreement any rights in other parties as third party beneficiaries of this Agreement, including, without limitation, the state of Illinois or any member. IN WITNESS WHEREOF, the parties have executed this agreement effective as of the date first written above. HOSPITAL: Name: MANAGED CARE ORGANIZATION: Name: Aetna Better Health, Inc., an Illinois Corporation City: By: Print: Title: Date: By: Print: Title: Date: 6 Aetna

12 Managed Care Organization Hospital Access Program Hospital Participation Agreement The undersigned hospital ( Hospital ) and the undersigned Medicaid Managed Care Organization ( MCO ) hereby agree to participate in the Managed Care Organization Hospital Access Program (the Program ) as of September 1, 2014, as follows: WHEREAS, the Illinois General Assembly has determined and authorized certain payments to preserve and improve access to hospital services for Medicaid beneficiaries, including those hospital access payments authorized under Sections 12.2 and 12.4 of Article V-A of the Illinois Public Aid Code ( Article V-A Hospital Access Payments ); and WHEREAS, the Illinois General Assembly has determined that at least 50% of Medicaid beneficiaries are to be enrolled in risk based care coordination or managed care programs by January 1, 2015; and WHEREAS, the Illinois General Assembly has articulated the importance of, and requested the cooperation of hospitals and the MCOs in preserving predictable sources of revenue to the state, including the federal funds generated through the Hospital Assessment Program, in order to preserve and assure access to hospital and other health care services for Medicaid beneficiaries as the Illinois Medicaid program increases the enrollment of beneficiaries in capitated managed care arrangements; and WHEREAS, the Illinois General Assembly has determined pursuant to the enactment of Public Act as enacted on June 16, 2014 (the Act ), that in order to assure continued access to hospital services that a portion of the access payments for hospitals, including those authorized under Article V-A of the Public Aid Code, shall be used to increase the capitation rates paid to MCOs for the purpose of increasing payments by MCOs for hospital services beginning in state fiscal year 2015; and WHEREAS, the purpose of the Program is for MCOs to provide payment (the MCO Hospital Access Payment ) to hospitals to assure access to hospital care to Medicaid beneficiaries in furtherance of the goals of the State of Illinois, as articulated by the General Assembly, to assure access to hospital services for Medicaid beneficiaries; and WHEREAS, each MCO receives specified monthly capitation rates (for purposes of the Program, such increased capitation rates are referred to as Enhanced Capitation ) from the Illinois Department of Healthcare and Family Services ( HFS ) specifically designated to be exclusively used by the MCOs to make the MCOs payments to hospitals as required by the Act and, in doing so, preserve and improve access to hospital services for Medicaid beneficiaries; and 1 Blue Cross Blue Shield of Illinois

13 WHEREAS, the Illinois Hospital Association ( IHA ) has agreed to help administer the Program and to receive payments from the MCOs on behalf of the hospitals that have designated IHA to do so by entering into a Hospital Participation Agreement with the MCO (the Participating Hospitals ); and WHEREAS, the MCO has determined that this Program would most effectively achieve the goals of the State of Illinois, as articulated by the Illinois General Assembly, to assure access to hospital services for Medicaid beneficiaries. NOW, THEREFORE, in consideration of the mutual covenants and conditions hereinafter set forth and other good and valuable consideration, the receipt of which is hereby acknowledged, the parties agree as follows: Definitions. For purposes of this Agreement, the following terms will have the definitions ascribed to them below. Access Payment means the monthly payment made by MCO to IHA or Hospital (see Section 2) based on the methodology described in Paragraph 4 of this Agreement. Article V-A Hospital Access Inpatient Payment Percentage means a fraction where: the numerator of which is the Article V-A Hospital Access Payments attributable to inpatient services for state fiscal year 2014 for Hospital; and the denominator of which is the Article V-A Hospital Access Payments attributable to inpatient services for state fiscal year 2014 for all hospitals in Hospital s HFS managed care region. Article V-A Hospital Access Outpatient Payment Percentage means a fraction where: the numerator of which is the Article V-A Hospital Access Payments attributable to outpatient services for the state fiscal year 2014 for a hospital; and the denominator of which is the Article V-A Hospital Access Payments attributable to outpatient services for state fiscal year 2014 for all hospitals in Hospital s HFS managed care region. Enhanced Capitation means that portion of MCO s capitation payment received from HFS specifically attributable to the Access Payments as authorized under Sections 5A-12.2(s) and (t) of the Illinois Public Aid Code. Existing Provider Contract means any contract between MCO and Hospital under which Hospital provides health care services to MCO s enrollees in exchange for reimbursement from MCO. HFS means the Illinois Department of Healthcare and Family Services or its successor. Hospital means the undersigned hospital, a hospital facility participating in the Illinois Medicaid program. 2 Blue Cross Blue Shield of Illinois

14 IHA means the Illinois Hospital Association. MCO means the undersigned managed care organization, an entity providing Medicaid benefits to beneficiaries under a contract with HFS. MCO Hospital Access Inpatient Payment means the product determined by multiplying the MCO s total Enhanced Capitation attributable to inpatient hospital services by Hospital s Article V-A Hospital Access Inpatient Payment Percentage. MCO Hospital Access Outpatient Payment means the product determined by multiplying the MCO s total Enhanced Capitation attributable to hospital outpatient services by Hospital s Article V-A Hospital Access Outpatient Payment Percentage. 1. Access Payments. MCO agrees to pay Access Payments to Hospital or its designated payee (see paragraph 2) on a monthly schedule. MCO s payment of Access Payments is expressly conditioned on MCO s receipt of Enhanced Capitation from HFS. The Parties agree that the Access Payments are for the purpose of ensuring continued access to hospital services for Illinois Medicaid beneficiaries. Access Payments do not replace or supplant any other amounts paid or payable to Hospital by MCO under any Existing Provider Contracts. 2. Hospital designates IHA to serve as its payee to receive payments under the Program from the MCO and directs the MCO to make such payments to IHA. To designate a Payee other than IHA, complete this paragraph: Notwithstanding any other provision in this agreement, to reject the above designation of IHA as its payee to receive payments under this agreement from MCO, Hospital must initial here:. Hospital directs the MCO to make payments under this agreement to {insert Hospital or other designated payee}. By selecting a payee other than IHA, Hospital agrees that IHA has no responsibility related to the issuance of payments to the Hospital under this agreement. Such election may also be revoked only by written notice to MCO. If Hospital utilizes IHA as its payee, MCO s liability for any given Access Payment is discharged in its entirety upon issuance of payment to IHA in accordance with this Agreement. If Hospital elects to maintain IHA as the default payee, Hospital agrees that any contract it enters into with IHA regarding the Access Payments will contain terms that require IHA to abide by the terms of this Agreement to the same extent as Hospital with regard to its obligations hereunder. 3 Blue Cross Blue Shield of Illinois

15 3. Each month, HFS will publish an Enhanced Capitation Rate Report. The report will, at a minimum, provide the per member, per month Enhanced Capitation amount attributable to each plan; the proportion of the Enhanced Capitation attributable to inpatient and outpatient hospital services; the number of enrollees for which the Enhanced Capitation is being paid; and the total Enhanced Capitation for that month. Upon receipt of the Enhanced Capitation Rate Report and the Enhanced Capitation amount the MCO shall, by the 24 th of each month or within three (3) business days of receiving the Enhanced Capitation Rate Report (whichever is later), review and notify IHA and HFS of any disagreements it has with the Enhanced Capitation Rate Report. 4. The IHA will be responsible for calculating the amount of the Access Payment payable by MCO to Hospital or its designated payee using the Enhanced Capitation Rate Report. The MCO will distribute the Access Payments to Hospital in a manner that replicates the distribution of hospital access payments under Article V-A of the Public Aid Code. Therefore, upon receipt of the Enhanced Capitation Rate Report and the Enhanced Capitation amount IHA shall by the 26 th of each month or within five (5) business days of receiving the Enhanced Capitation Rate Report, whichever is later, verify and notify in writing the chief executive officer of the MCO or his or her designee of the Hospital s payment from the Enhanced Capitation (the MCO Hospital Access Payment ) which shall consist of the sum of the MCO Hospital Access Inpatient Payment and the MCO Hospital Access Outpatient Payment as calculated for that given month. 5. Within four (4) business days (except for the transfer month of February in which transfer shall occur no later than the third (3 rd ) business day of the month), of notification by IHA of the correct Access Payment amount, the MCO shall transfer to the account designated by the Hospital or its designated payee, the MCO Hospital Access Payment owed to the Hospital, as identified under paragraph 4. In the event MCO has a disagreement with respect to a portion of the Enhanced Capitation amount, the MCO shall not delay the issuance of the MCO Hospital Access Payment to the Hospital with respect to any undisputed portion of the Enhanced Capitation amount and shall inform the Hospital or its designated payee of the basis for any adjustment to the MCO Hospital Access Payment. In no event shall MCO be obligated to make more in total MCO Hospital Access Payments than the undisputed Enhanced Capitation amount it has received. In the event the undisputed Enhanced Capitation amount for a given month is insufficient for MCO to pay the entirety of the Access Payments as calculated by IHA for each Hospital, the Access Payment shall be reduced by an amount proportional to the aggregate deficiency in the Enhanced Capitation. MCO shall not be obligated to make the remainder of the Access Payment until such time as the dispute is resolved or MCO has received the entirety of the scheduled Enhanced Capitation for that month. 6. Notwithstanding the foregoing, in no circumstances will MCO be required to pay the Access Payment until at least seven (7) business days following MCO s actual receipt of the Enhanced Capitation for the given month. By way of example, if MCO does not receive the Enhanced Capitation until the fourth business day following IHA notifying 4 Blue Cross Blue Shield of Illinois

16 MCO of the Access Payment amount, MCO will not be required to make the Access Payment until the eleventh business day following such notification. 7. The MCO agrees as follows: a. The MCO agrees to provide, within 10 days of receipt of a written request by the Hospital, a separate accounting of its Enhanced Capitation describing in detail the receipt by region and expenditure by hospital of all such Enhanced Capitation. Nothing in this section requires either Party to maintain a separate account with a financial institution specifically for the holding of funds paid under this Agreement. b. The MCO shall procure a surety bond in an amount determined by HFS to approximate one month s liability of its Enhanced Capitation authorized under Section 5A-12.2(s) of the Illinois Public Aid Code. c. Late Payments; Interest. In the event that MCO does not make the Access Payment to Hospital or its designated payee within the timeframes described above, MCO shall pay interest on any past due amounts at the rate of 9% per annum. In the event that the rate of 9% per annum exceeds the maximum rate permissible by law, MCO shall pay the maximum rate of interest otherwise allowed by law. 8. Nothing in the Program shall be construed or used by the MCO or Hospital as justification for seeking changes to its provider agreement with hospitals. Nothing in this Agreement is intended to modify any Existing Provider Contracts between the Parties. 9. The Program shall be in effect beginning in state fiscal year 2015 and shall continue as long as it is authorized under Illinois law. This agreement shall continue as long as the Program is in effect, unless terminated by the Hospital or the MCO or as required by law. Any party may terminate this agreement by providing at least sixty (60) days prior written notice to the other party. 10. This agreement constitutes the entire understanding between the parties with respect to this subject matter. No party may assign this agreement to another party without the prior written consent of the other parties, which consent shall not be unreasonably withheld. Any notices required under this agreement shall be given in writing to the chief executive officer of each party, unless a party has provided a written designation of another representative to receive such notices. This Agreement may only be amended in writing signed by both Parties. 11. This agreement may be executed in two or more counterparts, each of which shall be deemed an original, but all of which shall constitute one and the same instrument. Delivery of an executed counterpart of this Agreement by facsimile or electronic transmission in a Portable Document Format ( PDF ) shall be equally effective as 5 Blue Cross Blue Shield of Illinois

17 manual or mail delivery. Each counterpart, whether delivered manually, by mail, by facsimile or PDF, or by other electronic transmission, shall be deemed an original. 12. Disputes. The Parties agree to negotiate in good faith in order to address discrepancies in the amount of the Access Payments. In the event that a dispute cannot be resolved through good faith negotiation, the Parties agree to submit the dispute to arbitration under the Commercial Arbitration Rules of the American Arbitration Association as the exclusive means of resolving the dispute. Judgment on the award rendered in any such arbitration may be entered in any court of competent jurisdiction. 13. Except as is otherwise specifically provided in this Agreement, the parties have not created and do not intend to create by this Agreement any rights in other parties as third party beneficiaries of this Agreement, including, without limitation, the state of Illinois or any member. IN WITNESS WHEREOF, the parties have executed this agreement effective as of the date first written above. HOSPITAL: Name: City: By: Print: Title: Date: MANAGED CARE ORGANIZATION: Name: Health Care Service Corporation, a Mutual Reserve Company, operating through its division Blue Cross Blue Shield of Illinois By: Print: Title: Date: 6 Blue Cross Blue Shield of Illinois

18 Managed Care Organization Hospital Access Program Hospital Participation Agreement The undersigned hospital ( Hospital ) and the undersigned Medicaid Managed Care Organization ( MCO ) hereby agree to participate in the Managed Care Organization Hospital Access Program (the Program ) as of September 1, 2014, as follows: WHEREAS, the Illinois General Assembly has determined and authorized certain payments to preserve and improve access to hospital services for Medicaid beneficiaries, including those hospital access payments authorized under Sections 12.2 and 12.4 of Article V-A of the Illinois Public Aid Code ( Article V-A Hospital Access Payments ); and WHEREAS, the Illinois General Assembly has determined that at least 50% of Medicaid beneficiaries are to be enrolled in risk based care coordination or managed care programs by January 1, 2015; and WHEREAS, the Illinois General Assembly has articulated the importance of, and requested the cooperation of hospitals and the MCOs in preserving predictable sources of revenue to the state, including the federal funds generated through the Hospital Assessment Program, in order to preserve and assure access to hospital and other health care services for Medicaid beneficiaries as the Illinois Medicaid program increases the enrollment of beneficiaries in capitated managed care arrangements; and WHEREAS, the Illinois General Assembly has determined pursuant to the enactment of Public Act as enacted on June 16, 2014 (the Act ), that in order to assure continued access to hospital services that a portion of the access payments for hospitals, including those authorized under Article V-A of the Public Aid Code, shall be used to increase the capitation rates paid to MCOs for the purpose of increasing payments by MCOs for hospital services beginning in state fiscal year 2015; and WHEREAS, the purpose of the Program is for MCOs to provide payment (the MCO Hospital Access Payment ) to hospitals to assure access to hospital care to Medicaid beneficiaries in furtherance of the goals of the State of Illinois, as articulated by the General Assembly, to assure access to hospital services for Medicaid beneficiaries; and WHEREAS, each MCO receives specified monthly capitation rates (for purposes of the Program, such increased capitation rates are referred to as Enhanced Capitation ) from the Illinois Department of Healthcare and Family Services ( HFS ) specifically designated to be exclusively used by the MCOs to make the MCOs payments to hospitals as required by the Act and, in doing so, preserve and improve access to hospital services for Medicaid beneficiaries; and 1 HealthSpring of Illinois

19 WHEREAS, the Illinois Hospital Association ( IHA ) has agreed to help administer the Program and to receive payments from the MCOs on behalf of the hospitals that have designated IHA to do so by entering into a Hospital Participation Agreement with the MCO (the Participating Hospitals ); and WHEREAS, the MCO has determined that this Program would most effectively achieve the goals of the State of Illinois, as articulated by the Illinois General Assembly, to assure access to hospital services for Medicaid beneficiaries. NOW, THEREFORE, in consideration of the mutual covenants and conditions hereinafter set forth and other good and valuable consideration, the receipt of which is hereby acknowledged, the parties agree as follows: Definitions. For purposes of this Agreement, the following terms will have the definitions ascribed to them below. Access Payment means the monthly payment made by MCO to IHA or Hospital (see Section 2) based on the methodology described in Paragraph 4 of this Agreement. Article V-A Hospital Access Inpatient Payment Percentage means a fraction where: the numerator of which is the Article V-A Hospital Access Payments attributable to inpatient services for state fiscal year 2014 for Hospital; and the denominator of which is the Article V-A Hospital Access Payments attributable to inpatient services for state fiscal year 2014 for all hospitals in Hospital s HFS managed care region. Article V-A Hospital Access Outpatient Payment Percentage means a fraction where: the numerator of which is the Article V-A Hospital Access Payments attributable to outpatient services for the state fiscal year 2014 for a hospital; and the denominator of which is the Article V-A Hospital Access Payments attributable to outpatient services for state fiscal year 2014 for all hospitals in Hospital s HFS managed care region. Enhanced Capitation means that portion of MCO s capitation payment received from HFS specifically attributable to the Access Payments as authorized under Sections 5A-12.2(s) and (t) of the Illinois Public Aid Code. Existing Provider Contract means any contract between MCO and Hospital under which Hospital provides health care services to MCO s enrollees in exchange for reimbursement from MCO. HFS means the Illinois Department of Healthcare and Family Services or its successor. Hospital means the undersigned hospital, a hospital facility participating in the Illinois Medicaid program. 2 HealthSpring of Illinois

20 IHA means the Illinois Hospital Association. MCO means the undersigned managed care organization, an entity providing Medicaid benefits to beneficiaries under a contract with HFS. MCO Hospital Access Inpatient Payment means the product determined by multiplying the MCO s total Enhanced Capitation attributable to inpatient hospital services by Hospital s Article V-A Hospital Access Inpatient Payment Percentage. MCO Hospital Access Outpatient Payment means the product determined by multiplying the MCO s total Enhanced Capitation attributable to hospital outpatient services by Hospital s Article V-A Hospital Access Outpatient Payment Percentage. 1. Access Payments. MCO agrees to pay Access Payments to Hospital or its designated payee (see paragraph 2) on a monthly schedule. MCO s payment of Access Payments is expressly conditioned on MCO s receipt of Enhanced Capitation from HFS. The Parties agree that the Access Payments are for the purpose of ensuring continued access to hospital services for Illinois Medicaid beneficiaries. Access Payments do not replace or supplant any other amounts paid or payable to Hospital by MCO under any Existing Provider Contracts. 2. Hospital designates IHA to serve as its payee to receive payments under the Program from the MCO and directs the MCO to make such payments to IHA. To designate a Payee other than IHA, complete this paragraph: Notwithstanding any other provision in this agreement, to reject the above designation of IHA as its payee to receive payments under this agreement from MCO, Hospital must initial here:. Hospital directs the MCO to make payments under this agreement to {insert Hospital or other designated payee}. By selecting a payee other than IHA, Hospital agrees that IHA has no responsibility related to the issuance of payments to the Hospital under this agreement. Such election may also be revoked only by written notice to MCO. If Hospital utilizes IHA as its payee, MCO s liability for any given Access Payment is discharged in its entirety upon issuance of payment to IHA in accordance with this Agreement. If Hospital elects to maintain IHA as the default payee, Hospital agrees that any contract it enters into with IHA regarding the Access Payments will contain terms that require IHA to abide by the terms of this Agreement to the same extent as Hospital with regard to its obligations hereunder. 3 HealthSpring of Illinois

21 3. Each month, HFS will publish an Enhanced Capitation Rate Report. The report will, at a minimum, provide the per member, per month Enhanced Capitation amount attributable to each plan; the proportion of the Enhanced Capitation attributable to inpatient and outpatient hospital services; the number of enrollees for which the Enhanced Capitation is being paid; and the total Enhanced Capitation for that month. Upon receipt of the Enhanced Capitation Rate Report and the Enhanced Capitation amount the MCO shall, by the 24 th of each month or within three (3) business days of receiving the Enhanced Capitation Rate Report (whichever is later), review and notify IHA and HFS of any disagreements it has with the Enhanced Capitation Rate Report. 4. The IHA will be responsible for calculating the amount of the Access Payment payable by MCO to Hospital or its designated payee using the Enhanced Capitation Rate Report. The MCO will distribute the Access Payments to Hospital in a manner that replicates the distribution of hospital access payments under Article V-A of the Public Aid Code. Therefore, upon receipt of the Enhanced Capitation Rate Report and the Enhanced Capitation amount IHA shall by the 26 th of each month or within five (5) business days of receiving the Enhanced Capitation Rate Report, whichever is later, verify and notify in writing the chief executive officer of the MCO or his or her designee of the Hospital s payment from the Enhanced Capitation (the MCO Hospital Access Payment ) which shall consist of the sum of the MCO Hospital Access Inpatient Payment and the MCO Hospital Access Outpatient Payment as calculated for that given month. 5. Within four (4) business days (except for the transfer month of February in which transfer shall occur no later than the third (3 rd ) business day of the month), of notification by IHA of the correct Access Payment amount, the MCO shall transfer to the account designated by the Hospital or its designated payee, the MCO Hospital Access Payment owed to the Hospital, as identified under paragraph 4. In the event MCO has a disagreement with respect to a portion of the Enhanced Capitation amount, the MCO shall not delay the issuance of the MCO Hospital Access Payment to the Hospital with respect to any undisputed portion of the Enhanced Capitation amount and shall inform the Hospital or its designated payee of the basis for any adjustment to the MCO Hospital Access Payment. In no event shall MCO be obligated to make more in total MCO Hospital Access Payments than the undisputed Enhanced Capitation amount it has received. In the event the undisputed Enhanced Capitation amount for a given month is insufficient for MCO to pay the entirety of the Access Payments as calculated by IHA for each Hospital, the Access Payment shall be reduced by an amount proportional to the aggregate deficiency in the Enhanced Capitation. MCO shall not be obligated to make the remainder of the Access Payment until such time as the dispute is resolved or MCO has received the entirety of the scheduled Enhanced Capitation for that month. 6. Notwithstanding the foregoing, in no circumstances will MCO be required to pay the Access Payment until at least seven (7) business days following MCO s actual receipt of the Enhanced Capitation for the given month. By way of example, if MCO does not receive the Enhanced Capitation until the fourth business day following IHA notifying 4 HealthSpring of Illinois

22 MCO of the Access Payment amount, MCO will not be required to make the Access Payment until the eleventh business day following such notification. 7. The MCO agrees as follows: a. The MCO agrees to provide, within 10 days of receipt of a written request by the Hospital, a separate accounting of its Enhanced Capitation describing in detail the receipt by region and expenditure by hospital of all such Enhanced Capitation. Nothing in this section requires either Party to maintain a separate account with a financial institution specifically for the holding of funds paid under this Agreement. b. The MCO shall procure a surety bond in an amount determined by HFS to approximate one month s liability of its Enhanced Capitation authorized under Section 5A-12.2(s) of the Illinois Public Aid Code. c. Late Payments; Interest. In the event that MCO does not make the Access Payment to Hospital or its designated payee within the timeframes described above, MCO shall pay interest on any past due amounts at the rate of 9% per annum. In the event that the rate of 9% per annum exceeds the maximum rate permissible by law, MCO shall pay the maximum rate of interest otherwise allowed by law. 8. Nothing in the Program shall be construed or used by the MCO or Hospital as justification for seeking changes to its provider agreement with hospitals. Nothing in this Agreement is intended to modify any Existing Provider Contracts between the Parties. 9. The Program shall be in effect beginning in state fiscal year 2015 and shall continue as long as it is authorized under Illinois law. This agreement shall continue as long as the Program is in effect, unless terminated by the Hospital or the MCO or as required by law. Any party may terminate this agreement by providing at least sixty (60) days prior written notice to the other party. 10. This agreement constitutes the entire understanding between the parties with respect to this subject matter. No party may assign this agreement to another party without the prior written consent of the other parties, which consent shall not be unreasonably withheld. Any notices required under this agreement shall be given in writing to the chief executive officer of each party, unless a party has provided a written designation of another representative to receive such notices. This Agreement may only be amended in writing signed by both Parties. 11. This agreement may be executed in two or more counterparts, each of which shall be deemed an original, but all of which shall constitute one and the same instrument. Delivery of an executed counterpart of this Agreement by facsimile or electronic transmission in a Portable Document Format ( PDF ) shall be equally effective as 5 HealthSpring of Illinois