DHS Subcontractor Requirements Between Security Health Plan and Providers/Practices
Per BadgerCare Plus and Medicaid SSI Contract for January 1, 2022 – December 31, 2023. Click here to learn more about the BadgerCare Plus and Medicaid SSI contracting.
- Subcontract Standard Language
- Subcontractor uses only BadgerCare Plus and/or Medicaid SSI-enrolled providers in accordance with this Contract.
- No terms of this subcontract are valid which terminate legal liability of the HMO.
- Subcontractor agrees to participate in and contribute required data to HMO Quality Assessment/Performance Improvement programs.
- Subcontractor agrees to abide by the terms of this Contract for the timely provision of emergency and urgent care.Where applicable, subcontractor agrees to follow those procedures for handling urgent and emergency care cases stipulated in any required hospital/emergency room MOUs signed by the HMO in accordance with this Contract.
- Subcontractor agrees to submit HMO encounter data in the format specified by the HMO, so that the HMO can meet the Department specifications required by this Contract. The HMO will evaluate the credibility of data obtained from subcontracted vendors’ external databases to ensure that any patient-reported information has been adequately verified.
- Subcontractor agrees to comply with all non-discrimination requirements.
- Per 42 CFR 438.3(k), subcontractor agrees to comply with all audit and record retention and inspection requirements of 42 CFR 438.230(c)(3)(i-iv) and, where applicable, the special compliance requirements on abortions, sterilizations, hysterectomies, and HealthCheck reporting requirements. Specifically, the State (including the Office of Inspector General), CMS, the HHS Inspector General, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any books, records, contracts, computer or other electronic systems of the subcontractor, or of the subcontractor’s contractor, that pertain to any aspect of services and activities performed, or determination of amounts payable under the HMO’s contract with the State. This right to audit will exist through 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later.
- Any HMO or its subcontractor that enters into a contract with an entity outside the U.S. must clearly indicate Wisconsin law as jurisdiction for any breach of contract and ensure compliance with state and federal laws allowing for such contracts.
- Per 42 CFR 438.230, subcontractor agrees to provide representatives of the HMO, as well as duly authorized agents or representatives of the Department (including the Office of the Inspector General) and the federal Department of Health and Human Services, access to its premises and its contracts, medical records, billing (including contractual rates agreed upon between the HMO and the subcontractor), and administrative records. If the State (including the Office of the Inspector General), CMS, or the HHS Inspector General determines that there is a reasonable possibility of fraud or similar risk, the State, CMS, or the HHS Inspector General may inspect, evaluate, and audit the subcontractor at any time. Refusal will result in sanctions or penalties in Article XIV, Section C against the HMO for failure of its subcontractor to permit access to a Department or federal DHHS representative. Subcontractor agrees otherwise to preserve the full confidentiality of medical records in accordance with this Contract.
- Subcontractor agrees to the requirements for maintenance and transfer of medical records stipulated in this Contract.
- Subcontractor agrees to ensure confidentiality of family planning services.
- Subcontractor agrees not to create barriers to access to care by imposing requirements on members that are inconsistent with the provision of medically necessary and covered BadgerCare Plus and/or Medicaid SSI benefits (e.g., COB recovery procedures that delay or prevent care).
- Subcontractor agrees to clearly specify referral approval requirements to its providers and in any sub-subcontracts.
- Subcontractor agrees not to bill BadgerCare Plus and/or Medicaid SSI members for medically necessary services covered under this Contract and provided during the members’ period of HMO enrollment.Subcontractor also agrees not to bill members for any missed appointments while the members are eligible under the BadgerCare Plus and/or Medicaid SSI Programs. This provision will remain in effect even if the HMO becomes insolvent. However, if a member agrees in writing to pay for a non-covered service, then the HMO, HMO provider, or HMO subcontractor can bill.
The standard release form signed by the member at the time of services does not relieve the HMO and its providers and subcontractors from the prohibition against billing a BadgerCare Plus or Medicaid SSI member in the absence of a knowing assumption of liability for a non-covered service. The form or other type of acknowledgment relevant to BadgerCare Plus or Medicaid SSI member liability must specifically state the admissions, services, or procedures that are not covered by BadgerCare Plus or Medicaid SSI.
- Within 15 business days of the HMO’s request subcontractors must forward medical records pursuant to grievances or appeals to the HMO. If the subcontractor does not meet the 15 business day requirement, the subcontractor must explain why and indicate when the medical records will be provided.
- Subcontractor agrees to abide by the terms regarding appeals to the HMO and to the Department regarding the HMO’s nonpayment for services providers render to members.
- Subcontractor agrees to abide by the HMO marketing/informing requirements. Subcontractor will forward to the HMO for prior approval all flyers, brochures, letters and pamphlets the subcontractor intends to distribute to its members concerning its HMO affiliation(s), or changes in affiliation, or relating directly to the BadgerCare Plus and/or Medicaid SSI population. Subcontractor will not distribute any “marketing” or member informing materials without the consent of the HMO and the Department.
- Subcontractor agrees to abide by the HMO’s restraint policy, which must be provided by the HMO. Members have the right to be free from any form of restraint or seclusion used as a means of force, control, ease or reprisal.
- HMOs shall not prohibit providers outside the parent healthcare system from contracting with another HMO entity.
The HMO must ensure that all subcontracts are in writing and include the following standard language when applicable: