La. Admin. Code tit. 50 § I-3901

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-3901 - General Provisions

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.

La. Admin. Code tit. 50, § I-3901

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:1596 (June 2011), amended LR 41:943 (May 2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.