4th HMO Contract Amendment Anthem by 1szbxl

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									                                      STATE OF NEVADA
                               DEPARTMENT OF HUMAN RESOURCES                              MICHAEL J. WILLDEN
                    DIVISION OF HEALTH CARE FINANCING AND POLICY                               Director

                                1100 E. William Street, Suite 116
JIM GIBBONS                       Carson City, Nevada 89701                                CHARLES DUARTE
   Governor                                                                                  Administrator




                           AMENDMENT #4 TO CONTRACT 1509

                                  Between the State of Nevada
                                   Acting By and Through Its

              NEVADA DEPARTMENT OF HEALTH AND HUMAN RESOURCES
                 DIVISION OF HEALTH CARE FINANCING AND POLICY
                             1100 E. William Street, Suite 108
                                  Carson City, NV 89701
                          Ph: (775) 684-3708 Fax: (775) 684-4178
                            E-mail: gtanner@dhcfp.state.nv.us

                                              and

               HMO Colorado, Inc. dba Anthem Blue Cross Blue Shield Partnership Plan
                                          5150 Camino Ruiz
                                        Camarillo, CA 93012
                                       Contact: Randy Thomas
                              Phone: (805) 384-3348 Fax: (805) 384-3630
                               Email: Randy.S.Thomas@Wellpoint.com



    1.         AMENDMENTS. All provisions of the original contract dated November 1, 2006,
               remain in full force and effect with the exception of the following:

 Section 2.1.3.5:
       2.1.3.5           School-Based Child Health Services (SBCHS)
                         DHCFP has provider contracts with several school districts to provide
                         certain medically necessary covered services through School Based Child
                         Health Services (SBCHS) to eligible Title XIX Medicaid and Title XXI
                         Nevada Check-Up recipients.

 Section 2.1.3.9:
         2.1.3.9         Institutions for Mental Diseases (IMDs)
                         Federal regulations stipulate that Title XIX can only reimburse for services
                         to IMD/psychiatric hospital patients who are 65 years of age or older or
                         under the age of 21 years. Residents of IMD facilities who are 21 years of
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                   age to through 64 years of age are not eligible for enrollment with the
                   HMO. If a recipient begins receiving IMD services immediately before
                   he/she reaches age 21, services may continue to be provided until the
                   earlier of:
                   2.1.3.9.1       The date the recipient no longer requires the services; or
                   2.1.3.9.2       The date the recipient reaches age 22.
                   If a recipient is admitted to an IMD after HMO enrollment, the recipient
                   will be disenrolled.
Section 2 .2:
         2.2       ENROLLMENT AND DISENROLLMENT REQUIREMENTS AND
                   LIMITATIONS
                   The eligibility and enrollment functions are the responsibility of DHCFP
                   and the Nevada State Welfare Division (NSWD) Division of Welfare and
                   Supportive Services (DWSS). The Vendor shall accept each recipient who
                   is enrolled in or assigned to the Vendor by DHCFP and/or its enrollment
                   sections and/or for whom a capitation payment has been made by the
                   DHCFP to the Vendor. The first date a Medicaid or Nevada Check Up-
                   eligible recipient will be enrolled is not earlier than the applicable date in
                   the Vendor’s specified contract.
                   The Vendor must accept recipients eligible for enrollment in the order in
                   which they apply without restriction, up to the limits set under the
                   contract. The Vendor acknowledges that enrollment is mandatory except
                   in the case of voluntary enrollment programs that meet the conditions set
                   forth in 42 CFR 438.50(a). The Vendor will not, on the basis of health status
                   or need for health services, discriminate against recipients eligible to enroll.
                   The Vendor will not deny the enrollment nor discriminate against any
                   Medicaid or Nevada Check Up recipients eligible to enroll on the basis of
                   race, color or national origin and will not use any policy or practice that
                   has the effect of discrimination on the basis of race, color or national origin.
                   If the recipient was previously disenrolled from the Vendor as the result of
                   a grievance filed by the Vendor, the recipient will not be re-enrolled with
                   the Vendor unless the recipient wins an appeal of the disenrollment. The
                   recipient may be enrolled with another Vendor.
                   The Vendor is not financially responsible for any services rendered during
                   a period of retroactive eligibility. However, as described in section 2.2.2.1
                   herein, the Vendor will be responsible for all Medicaid newborns as of the
                   date of birth if the mother of the newborn was enrolled with the Vendor as
                   of the newborn’s date of birth. (Refer to section 2.2.2.2 regarding
                   enrollment of Nevada Check Up/SCHIP newborns.)


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                        The Vendor must notify a recipient that any change in status, including
                        family size and residence, must be immediately reported by the recipient
                        to the NSWD DWSS eligibility worker. The Vendor must provide DHCFP
                        with notification of all births and deaths.
Section 2 .2 .1:
         2.2.1          Enrollment of Pregnant Women
                        The eligibility of Medicaid applicants is determined by the Division of
                        Welfare and Supportive Services (DWSS). DWSS notifies the States
                        fiscal agent who enrolls the applicant. Letters are sent to the new
                        recipients requiring them to select a vendor or have a vendor
                        automatically assigned. The Vendor must have written policies and
                        procedures for enrolling pregnant women. Pregnant women will be
                        required to choose a Vendor at the time they submit their initial Medicaid
                        eligibility application. The chosen Vendor will be notified of the pregnant
                        women’s choice by the State’s fiscal agent agency. The Vendor shall be
                        responsible for all covered medically necessary obstetrical services and
                        pregnancy-related care commencing at the time of enrollment.
Section 2 .2 .2:
         2.2.2          Enrollment of Program Newborns
                        The Vendor must have written policies and procedures for enrolling
                        newborns of enrolled recipients. The Vendor is required to report births
                        electronically on a weekly basis to the DHCFP via the Provider Supplied
                        Data file located on the File Transfer Protocol (FTP) Bulletin Board System
                        (BBS). The Vendor will be responsible for all covered medically necessary
                        services included in the Vendor benefit package to the qualified newborn.


Section 2.3.1.1.25 under Enrollee Handbook is added:
         2.3.1.1.25     Explanation of fraud and abuse and how to report suspected cases of
                        fraud and abuse, including hotlines, e-mail addresses, and the address
                        and telephone number of the Vendor’s fraud and abuse unit.


Section 2.6.2.6– In addition to existing HEDIS Measures in Section 2.6.2 the following measures are added
for the HIFA waiver pregnancy population:

         2.6.2.6        Measurement & Methodology: These measures are required for the HIFA
                        pregnancy population. For these women, the measure assesses the
                        following facets of prenatal and postpartum care:




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                  2.6.2.6.1    Prenatal and Postpartum Care:
                               The percentage of women who delivered a live birth
                               between November 6th of the year prior to the
                               measurement year and November 5th of the measurement
                               year, who were continuously enrolled at least forty-three
                               (43) days prior to delivery through fifty-six (56) days after
                               delivery. For these women, the measure assesses the
                               following facets of prenatal and postpartum care:
                               2.6.2.6.1   Timeliness of Prenatal Care:
                                       The percentage of women in the denominator who
                                       received a prenatal care visit as a member of the
                                       HMO in the first trimester or within forty-two (42)
                                       days of enrollment in the HMO.
                               2.6.2.6.2   Postpartum Care:
                                       The percentage of women in the denominator who
                                       had a postpartum visit on or between twenty-one
                                       (21) days and fifty-six (56) days after delivery.
                  2.6.2.6.2    Frequency of Ongoing Prenatal Care:
                               The percentage of women who delivered a live birth
                               between November 6th of the year prior to the
                               measurement year and November 5th of the measurement
                               year, who were continuously enrolled at least forty-three
                               (43) days prior to delivery through fifty-six (56) days after
                               delivery, and received the expected number of prenatal
                               care visits, adjusted for gestational age and the month that
                               the member enrolled in the health plan. This measure uses
                               the same denominator and deliveries as the “Prenatal and
                               Postpartum Care” measure.
                               Following HEDIS methodology, rates are to be reported as
                               those women who received <21 percent, and 81-100 percent
                               of the expected number of prenatal care visits.
                  DHCFP and/or the EQRO may conduct on-site review as needed to
                  validate medical measures reported.




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Section 2.6.2.7 In addition to existing HEDIS Measures in Section 2.6.2 the following HEDIS measure is
added and required for Title XIX and Title XXI recipients:
         2.6.2.7       Use of Appropriate Medications for People With Asthma (ASM)
                       The percentage of members 5–56 years of age during the measurement
                       year who were identified as having persistent asthma and who were
                       appropriately prescribed medication during the measurement year.
                       2.6.2.7.1       Numerator: The number of members in the denominator
                                       who received at least one dispensed prescription for
                                       inhaled corticosteroids, nedocromil, cromolyn sodium,
                                       leukotriene modifiers, or methylxanthines during the
                                       measurement year. The results will be reported by the
                                       following age groups: Ages 5–9 Years; Ages 10–17 Years;
                                       Ages 18–56 Years; Combined Rate (Ages 5–56 Years).
                       2.6.2.7.2       Denominator: The number of enrolled members 5–56
                                       years of age as of December 31 of the measurement year,
                                       who were identified as having persistent asthma during
                                       both the measurement year and the year prior to the
                                       measurement year. Members must also have been
                                       continuously enrolled in the health plan during both the
                                       measurement year and the year prior to the measurement
                                       year. Refer to the most recent version of the HEDIS
                                       Technical Specifications, Volume 2 for the exact measure
                                       specifications, including the definition of persistent
                                       asthma, continuous enrollment, asthma medications, and
                                       potential exclusions.
                       2.6.2.7.3       The most recent HEDIS Technical Specifications, Volume 2,
                                       will be used for reporting this measure. The health plans
                                       must use audited data, and are responsible for ensuring all
                                       updates to the measure are reflected in the final, reported
                                       rates.
                       DHCFP and/or the EQRO may conduct on-site review as needed to
                       validate medical measures reported.
         2.6.2.6 8             Plan of Correction (POC) Procedure




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Section 2.8.2.2 shall be amended as follows:


         2.8.2.2         Identify the race, ethnicity and primary language spoken of each
                         enrolled recipient whom provided that optional information on
                         their application. Section 2.8.2.2 will be negotiated with the Vendors
                         through an amendment once systems have been developed to
                         identify the race, ethnicity, and primary language spoken of each
                         enrolled recipient; The Vendors will work collaboratively with
                         DHCFP to validate determine enrollee race and ethnicity . This
                         data will be utilized to gather baseline data and will lead to the
                         development of a Performance Improvement Projects (PIP) or
                         quality improvement project. Such a project will incorporate data
                         from the State enrollment file according to the race and ethnicity
                         categories as defined by CMS. The data will be used to generate
                         stratified reports as recommended by the Centers for Medicare
                         and Medicaid Services and compliant with the Health Insurance
                         Portability and Accountability Act (HIPAA) for race and ethnicity
                         categories to identify disparities. The MCO’s will organize
                         interventions specifically designed to reduce or eliminate
                         disparities in health care.

 Section 2.9.4.4:
       2.9.4.4           The Vendor shall allow network and non-network providers to submit an
                         initial claim for covered services. The Vendor shall allow all network
                         providers to submit claims for reimbursement up to ninety (90) days from
                         the last date of service and non-network providers one hundred and eighty
                         (180) days from the last date of service unless a shorter time period is
                         negotiated. Vendor shall allow providers of emergency transportation 180
                         days from the last date of service to submit claims for reimbursement.
                         The Vendor’s claims payment system shall use standard claim forms
                         wherever possible. In addition, the Vendor shall have the capability to
                         electronically accept and adjudicate claims


Section 2.10.2.2 is amended as follows:

         2.10.2.2         State Fair Hearings
                          Pursuant to Nevada Revised Statute 422.306, when a provider has
                          exhausted the Vendor’s internal appeals process, the provider has the right
                          to submit a written request to the DHCFP for a State Fair Hearing. It is the


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                          Vendor’s responsibility to notify the provider of this right at the time the
                          provider enters into a contract with the Vendor and when the outcome of
                          an appeal is not wholly in favor of the provider pursuant to 42 CFR
                          431.200(b); 42 CFR 431.220(5); 42 CFR 438.414; and 42 CFR 438.10(g)(1).
                          Disputes eligible for the State Fair Hearing process include:
                                 2.10.2.2.1       Denial or limited authorization of a requested
                                                         service;
                                 2.10.2.2.2       Reduction, suspension or termination of a previously
                                                  authorized service;
                                 2.10.2.2.3       Denial, in whole or in part, of payment for a service;
                                 2.10.2.2.4       Demand for recoupments; or,
                                 2.10.2.2.5       Failure of the Vendor to meet specified timeframes
                                                  (e.g., authorization, claims processing, appeal
                                                  resolution).
                          The DHCFP will not accept requests for State Fair Hearings that address
                          provider enrollment, termination or other contract disputes between the
                          Vendor and its providers and/or subcontractors. Likewise, grievances as
                          defined in Section 2.10.1 are not eligible for State Fair Hearings. The
                          Vendor is bound by the decision of the Fair Hearing Officer and must
                          comply with any decision resulting from the Fair Hearing process.

Section 2.11.5.2:

         2.11.5.2.       The Vendor shall collect and submit service specific encounter data in the
                         appropriate CMS 1500 or UB92, UB 04, and the/or appropriate ADA
                         Dental Claim format or an alternative format if prior approved by DHCFP.
                         The data shall be submitted in accordance with the requirements set forth.
                         The data shall include all services reimbursed by Medicaid.
Under Section 2.12.3.10 the following section is added is added:
         2.12.3.11       DHCFP retains the right to review contracts between the Vendor and
                         providers. DHCFP agrees to protect the terms of Vendor-Provider
                         contracts, if the Vendor clearly label individual documents as a "trade
                         secret" or "confidential"” as per section 23 of attachment C Contract Form
                         of contract.




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Under Section 2.12.8 the following section is added:

         2.12.8 Fraud and Abuse

         Vendor or any subcontractor that receives or makes annual payments under the State
         Plan of at least $5,000,000, as a condition of receiving such payments, shall:

         2.12.8.1.1        Establish written policies for all employees of the entity (including
                           management), and of any contractor or agent of the entity, that provide
                           detailed information about the False Claims Act established under sections
                           3729 through 3733 of Title 31, United States Code, administrative remedies
                           for false claims and statements established under chapter 38 of Title 31,
                           United States Code, any State laws pertaining to civil or criminal penalties
                           for false claims and statements, and whistleblower protections under such
                           laws, with respect to the role of such laws in preventing and detecting
                           fraud, waste, and abuse in Federal health care programs (as defined in
                           section 1128B(f)) of the Social Security Act of 1932; and

         2.12.8.1.2        Include as part of such written policies, detailed provisions regarding the
                           entity’s policies and procedures for detecting and preventing fraud, waste,
                           and abuse; and

         2.12.8.1.3          Include in any employee handbook for the entity, a specific discussion of
                           the laws described in 2.12.8.1, the rights of employees to be protected as
                           whistleblowers, and the entity’s policies and procedures for detecting and
                           preventing fraud, waste, and abuse.

         2.12.8.4 Vendor shall:

                   2.12.8.4.1        Adhere to federal and state regulations, and the provider
                                     agreement, to establish written policy for dissemination to their
                                     staff;
                   2.12.8.4.2        Ensure policies are adopted by any contractor or agent acting on
                                     their behalf; Educate staff on the regulations.
                   2.12.8.4.3        Dissemination to new staff should occur within 30 days from the
                                     date of hire;
                   2.12.8.4.4        Provide signed Certification Form, signed provider agreement,
                                     copies of written policy and employee handbook,
                   2.12.8.4.5        and documentation staff has been educated, within the required
                                     timeframes;
                   2.12.8.4.6        Maintain documentation on the education of staff, and make it
                                     readily available for review by state or federal officials; and


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                   2.12.8.4.7     Provide requested re-certification within required timeframes to
                                  ensure ongoing compliance.
          2.12.8.5         The vendor shall include terms in its subcontracts requiring its
                           subcontractors to comply with section 2.12.8

Section 2.13.5:
 2.13.5              Recipient Satisfaction Reporting
                     Each Vendor must collect and submit to DHCFP a statistically valid uniform data
                     set a child and adult CAHPS survey measuring recipient satisfaction prior to the
                     third quarter of each contract year, unless the requirement is waived by DHCFP
                     due to an EQRO performed survey. This may be done in conjunction with the
                     Vendor’s own satisfaction survey. DHCFP requires data stratified to indicate the
                     satisfaction level of parents or guardians of Nevada Check Up participants.
                     DHCFP may request a specific sample, and/or survey tool. Survey results must be
                     disclosed to the State, and, upon State’s or enrollee’s request, disclosed to enrollees.


Section 2.13.7:
2.13.7               Fraud and Abuse Reporting
                     The Vendor must provide DHCFP with monthly reports documenting the
                     number and types of disciplinary actions, sanctions, and suspected or confirmed
                     cases of fraud and abuse received by the Vendor and its subcontractors. Reports
                     must be submitted within fifteen (15) business days after close of the month to
                     which they apply. This report is added to Attachment F, Section 3 of the Forms
                     and Reporting Guide.
                     The Vendor and its subcontractors must provide immediate notification to DHCFP
                     regarding all suspected recipient and provider fraud and abuse pursuant to 42 CFR
                     455.17 15.
                     Upon the Vendor’s awareness of any disciplinary action, sanction taken against a
                     network provider, or any suspected fraud or abuse, the Vendor shall immediately
                     inform DHCFP.
                     The Vendor and/or its subcontractors are responsible for informing DHCFP of any
                     suspected recipient fraud or abuse.
                     These reporting requirements shall be included in all Vendor subcontracts.




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Section 2.13.8 is changed to the following:
  2.13.8            Network Adequacy
                    The Vendor and its subcontractors must provide DHCFP with quarterly
                    reports documenting the access and availability of its network. Reports must be
                    submitted within forty five (45) business days after close of the quarter to which
                    they apply. This report is added to Attachment F, Section 6 of the Forms and
                    Reporting Guide


Section 2.13.9 is added:
  2.13.9            Hospital Adequacy
                    The Vendor must provide DHCFP with a quarterly report on the adequacy of
                    contracted hospitals to the assigned recipient caseload. The report shall
                    document the number and types of specialties covered by contracted hospitals.
                    Reports must be submitted within forty five (45) business days after close of the
                    quarter to which they apply. This report is added to Attachment F, Section 6 of
                    the Forms and Reporting Guide.


Section 2.13.10 is added:
  2.13.10           Out of State Services
                    The Vendor and its subcontractors must provide DHCFP with quarterly
                    reports documenting the number and types of services provided to Nevada
                    Medicaid recipients out side of the state of Nevada or its catchments. The report
                    shall document the reasons the services were provided out of state. Reports must
                    be submitted within forty five (45) business days after close of the quarter to
                    which they apply. This report is added to Attachment F, Section 6 of the Forms
                    and Reporting Guide.
  2.13.8 11         Other Reporting
                    The Vendor shall be required to comply with additional reporting requirements
                    upon the request of DHCFP. Additional reporting requirements may be imposed
                    on the Vendor if DHCFP identifies any area of concern with regard to a particular
                    aspect of the Vendor’s performance under this contract. Such reporting would
                    provide DHCFP with the information necessary to better assess the Vendor’s
                    performance.




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Section 2.16 shall be amended as follows:

2.16               Performance Standards and Incentives

                   Within the initial contract period, the Vendor is expected to collaborate with
                   DHCFP in the development of a health outcomes incentive structure. The objective
                   is to establish specific performance incentive standards which are jointly agreed
                   upon by the Vendor and DHCFP.
                   When established, the performance standards will be the basis for potential
                   incentive payment to the Vendor. For reporting periods in which the Vendor’s
                   performance is above standard, DHCFP will provide an incentive payment. The
                   payment is subject to legislatively approved funding in the fiscal year of the
                   proposed payment distribution. In addition, the incentive payment methodology
                   shall comply with 42 CFR 438.6(c)(5)(iv).
                   RFP Section 2.6.2 requires the Vendor to perform HEDIS measures for Medicaid
                   clients that include Well-Child visits (see 2.6.2.2.2) and Annual Dental Visits (see
                   2.6.2.5.3), and Immunizations (see 2.6.2.3.1).
                          2.16.1.1 Annual Dental Visit,
                          2.16.1.2 All three Well-Child Visits measures, and
                          2.16.1.3 Childhood Immunization Status Combination 2.
                   The Vendor may receive a monetary incentive payment based on the measured
                   performance for a calendar year as well as for improvement in performance from
                   calendar to calendar year as reported, respectively (improvement measure). The
                   lump sum payment will be computed as a per-member per- month amount
                   multiplied by the average monthly enrollment for the first six (6) months of a
                   calendar year multiplied by twelve (12). The total payment will be comprised of six
                   (6) independent calculations, as described in more detail below. Total quality
                   incentive payments for all measures to all Vendors by DHCFP will be subject to a
                   maximum annual amount of one million dollars. If the calculated payments exceed
                   the maximum then all payments will be proportionately reduced such that the total
                   equals the maximum. The full per-member-per-month amount payable for each of
                   the six (6) incentive calculations is twenty (20) cents. The payment for each
                   measure is computed independently, with a maximum payment of $70,000 each.
                   The incentive payments may be adjusted to address DHCFP perceived distortions
                   in the computed payments resulting from unanticipated circumstances affecting
                   the payment formula. An example of a situation that could lead to such
                   adjustments is dramatic shifts in enrolled member months over the analysis
                   periods. A new Vendor will not be eligible for an incentive payment in the first
                   contract year as HEDIS measures are reported in each year for performance in



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                  the year prior. In the second contract year, payment potential will exist for the
                  Current Measure only. In the third contract year, the Vendor will participate in
                  both the Current Measure and the Improvement Measure computations.
                  Current Measure
                  For each performance measure in a calendar year, the incentive will be paid in full
                  if it is reported at or above the national HEDIS 90th percentile. No incentive
                  payment will be made if the reported amount is at or below the national HEDIS
                  mean. The incentive payment will be pro rated if performance is reported between
                  the national HEDIS mean and 90th percentile. The most current national Medicaid
                  HEDIS means and 90th percentiles available at the time of the report and 90th
                  percentile available will be used. The computation of the pro-rated amount will be
                  a simple linear interpolation that compares the actual score to the mean and 90th
                  percentile scores.
                  Improvement Measure
                  Normalized Improvement from calendar year to calendar year is computed by
                  taking the nominal improvement and dividing by the maximum possible
                  improvement. For each measure, Normalized Improvement of 10% or more will
                  result in full payment of the allowable incentive. Failure to improve will result in
                  no incentive payment. The incentive payment will be pro-rated if the Normalized
                  Improvement is positive but less than 10%.
                  Non-Incentive Measures
                  The Non-Incentive Measures include Children and Adolescents’ Access to
                  Primary Care Practitioners, Prenatal and Postpartum Care, Frequency of Ongoing
                  Prenatal Care (<21%, and 81-100% of recommended visits), Follow-Up After
                  Hospitalization for Mental Illness, Use of Appropriate Medications for People
                  With Asthma.
                  HEDIS rates for non-incentive measures will also be evaluated. If the non-
                  incentive HEDIS measures are determined to be Not Reportable (NR) based on
                  a biased rate as determined by the Certified HEDIS Compliance Auditor or if
                  rates demonstrate a measurable decline, DHCFP will reduce the payment
                  disbursement by 25% of the gross amount for each measure that shows a
                  decline. A measurable decline is defined as a rate that is less than 97% of the
                  level reported in the prior year. The measurable decline rule will only apply to
                  measures with 100 or more eligible cases in the denominator to ensure the
                  decline is not a function of small sample sizes. A rate that decreases, but still
                  remains at or above the most recent Medicaid HEDIS 90th percentile for the
                  measure is also exempt from the 97 percent rule. Additionally, changes in the
                  HEDIS Technical Specifications for a measure may impact rates, and therefore,




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                   the State will review any changes in specifications to determine whether or not
                   the measure should be included.


                   Provider Pass-Through
                   The vendor is subject to the requirement that 20% of the net incentive payment
                   be passed directly to providers based on encounter data records for
                   immunizations, well child visits, referrals and screenings. The state will work
                   with the Vendor to design a process for this pass-through payment to occur.
                   If a new Vendor is procured, the Vendor must establish baseline performance levels
                   in its first contracted year. Performance incentives will be considered in the
                   subsequent contract year if improvement is shown.



2.      INCORPORATED DOCUMENTS. Exhibit A (Original Contract) and are attached
hereto, incorporated by reference herein and made a part of this amended contract.

3.      REQUIRED APPROVAL. This amendment to the original contract shall not become
effective until and unless approved by the Nevada State Board of Examiners.




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 IN WITNESS WHEREOF, the parties hereto have caused this amendment to the original
contract to be signed and intend to be legally bound thereby.




Independent Contractor's Signature              Date             Title




DIVISION OF HEALTH CARE FINANCING AND POLICY




                                                 Administrator

Charles Duarte                           Date   Title




NEVADA DEPARTMENT OF HUMAN RESOURCES



                                                Director
Michael J. Willden                       Date   Title



APPROVED BY BOARD OF EXAMINERS                  Approved as to form by:




Signature - Board of Examiners           Deputy Attorney General for Attorney General

On                                               On




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                           ATTACHMENT A

                  AMENDMENT #4 TO CONTRACT 1509




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        State of Nevada Division of Health Care Financing and Policy
                              False Claims Act Certification Form



This is to certify that_________________________________, _____________________
                       (Provider Name)                          (Provider #)
                                                        _____________________
                                                        (Additional #, if applicable)
at______________________________________________________________________
   (Street Address)
________________________, _________________, _______________________
(City)                               (State)              (Zip Code)

on this ________ day of ____________________, 20___, has complied with the following requirements
established under section 1396a(a)68 of Title 42, United States Code:

Check box
      Established written policies, for all employees, providing detailed information about:
           a) False Claims Act established under sections 3729 through 3733 of Title 31, United States
               Code; and
           b) Administrative remedies for false claims and statements established under chapter 38 of
               Title 31, United States Code; and
           c) State laws, under NRS 357, NRS 422.410 – 570, and NRS 193.130, pertaining to civil or
               criminal penalties for false claims and statements; and
           d) Whistleblower protections under NRS 357.240 - 250, with respect to the prevention and
               detection of fraud, waste, and abuse in Federal health care programs.

      Included in the written policies, detailed provisions regarding policies and/or procedures for
       detecting and preventing fraud, waste, and abuse.

      Included in an employee handbook (if one exists), a specific discussion of the laws, the rights of
       employees to be protected as whistleblowers, and policies and procedures for detecting fraud, waste,
       and abuse.

      Educated staff, on the above mentioned regulations, within 30 days of the date of hire.

Signature ___________________________________
          (Administrator/Authority)

            ___________________________________, ___________________________
            Print Name                           Title

Completion of this certification does not exempt a facility or agency from on-site compliance monitoring.
Compliance may be assessed during visits by any agency or program within the Nevada Department of Health
and Human Services. In addition, DHCFP reserves the right to make any on-site visits deemed necessary for the
express purpose of determining compliance with these regulations.




                                                                                                          1
                FORMS AND REPORTING GUIDE



                                                 TABLE OF CONTENTS


                                        ENROLLEE AND PROVIDER
                                   GRIEVANCE AND APPEALS REPORTING

                  ENROLLEE AND PROVIDER FRAUD INVESTIGATION FORMS



                                                            SECTION 3


                                                                                                           Page Number


3.1      Purpose and Objective ................................................................................... 2


3.2      Effective Dates and Reporting Time Frames ................................................. 2


3.3      Resolution Reporting Table ............................................................................ 3


3.4      Instructions for Reporting ............................................................................... 4




Appendix A – Reporting Forms ..............................................................................6

Appendix B – Fraud Investigation Forms ……..……………………………..……12




                                                                                                               Section 3 – Page 1
                                                         Forms and Reporting Guide
                             Enrollee and Provider Grievance and Appeals – Section 3




3.    ENROLLEE AND PROVIDER GRIEVANCE AND APPEALS REPORTING


3.1   PURPOSE AND OBJECTIVE

      Under current federal regulations (42 CFR Part 438 Subpart F), Medicaid managed care
      organizations must have an internal process that provides for prompt resolution of enrollee
      grievances and appeals, are approved by the State, and assure that individuals with
      authority to require corrective action are involved in the process. In addition, Medicaid
      law requires managed care organizations to provide enrollees with access to the State Fair
      Hearing process if an appeal is not resolved wholly in favor of the enrollee.

      Nevada Medicaid managed care organizations are also required to establish an internal
      process that provides for prompt resolution of provider grievance and appeals. Nevada
      Revised Statute 422.306 requires that, when an appeal is not decided wholly in favor of the
      provider through the managed care organization’s internal process, the provider has the
      right to request a State Fair Hearing from the DHCFP.

      In the course of resolving grievances or appeals, as in the normal course of business,
      Medicaid managed care organizations may encounter situations in which enrollees or
      providers are suspected of Medicaid fraud. Per Section 2.9.1(B), the managed care
      organization may even shorten the timeframe for issuing Notices of Action if an enrollee is
      suspected of fraud. To assist managed care organizations in reporting suspected enrollee
      or provider fraud to the government entity authorized to investigate, Appendix B of this
      Section includes the appropriate forms. When fraud is suspected, the managed care
      organizations are required to submit investigation forms to the DHCFP immediately.


3.2   EFFECTIVE DATES AND REPORTING TIME FRAMES

      The provisions and requirements of this guide are part of the contract and are effective
      upon contract start date of July 1, 2006. All reports in Section 3 are due 45 business days
      following the end of the quarter or 15 day from the end of the month to which the report
      applies.




                                                                             Section 3 – Page 2
                                                    Forms and Reporting Guide
                        Enrollee and Provider Grievance and Appeals – Section 3


 3.3   RESOLUTION REPORTING TABLE



TABLE 1


REPORTING REQUIREMENTS



 Number                 Description                                 Due Date



Report 1         MCO/Subcontractor Grievance              45 business days following
                      Reporting Form                             quarter-end

Report 2         Notice of Action (NOA) Reporting Form    45 business days following
                                                                 quarter-end


Report 3         MCO Appeals Reporting Form               45 business days following
                                                                 quarter-end


Report 4         Subcontractor’s Appeals Reporting Form   45 business days following
                                                                 quarter-end



Report 5         MCO Provider Dispute Reporting Form      45 business days following
                                                                 quarter-end


Report 6         Subcontractor’s Provider Dispute         45 business days following
                       Reporting Form                            quarter-end

Report 7         MCO Provider/Enrollee fraud and          15 business days following
                      Abuse Reporting Form                       month end




                                                                   Section 3 – Page 3
                                                          Forms and Reporting Guide
                              Enrollee and Provider Grievance and Appeals – Section 3


3.4   INSTRUCTIONS FOR REPORTING


      REPORT 1 – MCO/SUBCONTRACTOR ENROLLEE GRIEVANCE REPORTING
      FORM

      For each month of the calendar year, report the number of enrollee grievances received,
      whether verbal or written. The information must include grievances relating to the managed
      care organization (MCO) and/or primary care physician or primary care site operation
      activities, or behavior that pertains to, but not limited to: availability, delivery or quality of
      care, and acceptability. The Grievance Report must also include all grievances received,
      whether verbal or written, by the MCO’s subcontractor(s) that are delegated this
      responsibility or have the responsibility to refer grievances to the MCO for resolution. The
      reported information must indicate the time frame for resolution completion, i.e., less than or
      equal to ninety (90) days or greater than ninety (90) days.

      REPORT 2 – NOTICE OF ACTION (NOA) REPORTING FORM

      For each month of the calendar year, report the number of notices of action (NOA) provided
      to enrollees and providers, and the time frame in which the notices were sent, i.e., less than
      or equal to 10 days before the date of action or greater than 10 days before the date of
      action. An NOA is required to be provided timely for each action taken on every service
      authorization request, regardless of requestor and whether written or oral. The NOA Report
      must also include all notices provided by the MCO’s subcontractor(s) that are delegated this
      responsibility.

      REPORT 3 – MCO ENROLLEE APPEAL REPORTING FORM

      For each month of the calendar year, report the number of enrollee appeal requests received.
      Appeal requests are related to a denial of a service authorization, reduction or termination of
      current services or other service limitations. The reported information must indicate the time
      frame for appeal completion, i.e., less than or equal to thirty (30) days or greater than thirty
      (30) days for standard appeal resolution and less than or equal to three (3) days or greater
      than three (3) days for expedited appeal resolution. The report must also indicate how many
      enrollees were referred to the DHCFP for access to a State Fair Hearing.

      REPORT 4 – SUBCONTRACTOR ENROLLEE APPEAL REPORTING FORM

      For each month of the calendar year, report the number of enrollee appeal requests received
      by any subcontractor to whom this responsibility has been delegated. Appeal requests are
      related to a denial of a service authorization, reduction or termination of current services or
      other service limitations. The reported information must indicate the time frame for appeal
      completion, i.e., less than or equal to thirty (30) days or greater than thirty (30) days for

                                                                                 Section 3 – Page 4
                                                    Forms and Reporting Guide
                        Enrollee and Provider Grievance and Appeals – Section 3


standard appeal resolution and less than or equal to three (3) days or greater than three (3)
days for expedited appeal resolution. The report must also indicate how many enrollees
were referred by the subcontractor to the DHCFP for access to a State Fair Hearing.

REPORT 5 – MCO PROVIDER GRIEVANCE AND APPEAL REPORTING FORM

For each month of the calendar year, report the number of provider grievances and appeals
received, whether verbal or written. The reported information must include provider
dispute issues pertaining but not limited to: policy and procedures issues, denied claims
and any claim issues with regard to processing time. The reported information must
indicate the time frame for resolution completion, i.e., less than or equal to thirty (30)
days or greater than thirty (30) days for appeal resolution and less than or equal to ninety
(90) days or greater than ninety (90) days for grievance resolution. The report must also
indicate how many providers were referred to the DHCFP for access to a State Fair
Hearing.

REPORT 6 – SUBCONTRACTOR PROVIDER GRIEVANCE AND APPEAL
REPORTING FORM

For each month of the calendar year, report the number of provider grievances and appeals
received, whether verbal or written, by any subcontractor to whom this responsibility has
been delegated. The reported information must include provider dispute issues pertaining
but not limited to: policy and procedures issues, denied claims and any claim issues with
regard to processing time. The reported information must indicate the time frame for
resolution completion, i.e., less than or equal to thirty (30) days or greater than thirty (30)
days for appeal resolution and less than or equal to ninety (90) days or greater than ninety
(90) days for grievance resolution. The report must also indicate how many providers
were referred by the subcontractor to the DHCFP for access to a State Fair Hearing.

Report 7 – MCO PROVIDER/ENROLLEE FRAUD AND ABUSE
REPORTING FORM

For each month of the calendar year, report the number of cases and suspected cases
of provider and enrollee fraud and abuse. The reported information must include the
number of providers sanctioned and the number of ongoing investigations carried
over from the previous time period.




                                                                          Section 3 – Page 5
                            Forms and Reporting Guide
Enrollee and Provider Grievance and Appeals – Section 3


      APPENDIX A


 Resolution Reporting Forms




                                       Section 3 – Page 6
                            Forms and Reporting Guide
Enrollee and Provider Grievance and Appeals – Section 3




       APPENDIX B

  Fraud Investigation Forms




                                       Section 3 – Page 7
Report 7 – MCO PROVIDER/ENROLLEE FRAUD AND ABUSE
REPORTING FORM

            NEVADA DIVISION OF HEALTH CARE FINANCING AND POLICY
                    MEDICAID PROVIDER FRAUD INVESTIGATION FORM

Referral Date: _________________________________________________________________

MCO Reporting Fraud: __________________________________________________________

Contact Reporting Possible Fraud: ________________________________________________

Phone Number of Contact: _______________________________________________________

Provider Name: _______________________________________________________________

Provider’s Medicaid Number: ____________________________________________________

Report of suspected fraud:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(Please use back of report form, if more space is needed)

     Check if written documentation was requested and received. (Please attach copy)

Provider’s Address: ___________________________________________________________

_____________________________________________________________________________

Provider’s Phone Number: ______________________________________________________
________________________________________________________________________
DHCFP USE ONLY

     Called SURS Supervisor to Report Fraud at (775) 684-3607.

Follow-up Instructions: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
            NEVADA DIVISION OF HEALTH CARE FINANCING AND POLICY
                    MEDICAID RECIPIENT FRAUD INVESTIGATION FORM


Referral Date: ________________ HMO Reporting Fraud: ____________________________

Recipient Name: _______________________________________________________________
Address: _____________________________________________________________________
DOB: ______________ Medicaid Eligibility Period (if known): ________________________
Medicaid Enrollment Period (if known): ____________________________________________
Medicaid Billing #:__________________ Social Security # (if known): __________________

Name of MCO Staff/Provider making report: ________________________________________
Phone Number of person making report: ____________________________________________
Please describe suspected fraud: ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(Please use back of report form, if more space is needed)
________________________________________________________________________
DHCFP USE ONLY

    Called Chief for Investigations & Recovery for Nevada State Welfare to Report Fraud at
    (775) 684-0559. (Name of DHCFP making referral: ____________________________)

Follow-up Instructions: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________


                                                                                             9
             Report 7 – MCO PROVIDER/ENROLLEE FRAUD AND ABUSE
             REPORTING FORM


                                                          MCO PROVIDER

                                            FRAUD AND ABUSE REPORT FORM
MCO NAME:

Report Quarter / Year:



                                            TOTAL NUMBER OF
    TYPE OF PROVIDER                      SUSPECTED FRAUD AND                      TOTAL NUMBER OF SUSPECTED FRAUD
        DISPUTE                            ABUSE CARRIED OVER                       AND ABUSETHIS REPORTING PERIOD
                                         FROM PREVIOUS REPORT



      Provider Sanctions


  Suspected Provider Fraud
         and Abuse

  Suspected Enrollee Fraud
         and Abuse

   *Other Fraud and Abuse
           Issues

            TOTALS




TOTAL NUMBER OF NETWORK PROVIDERS:


TOTAL NUMBER OF ENROLLEES ASSIGNED TO PLAN

TOTAL NUMBER OF NETWORK PROVIDERS
SANCTIONED OR SUSPECTED OF FRAUD AND ABUSE

TOTAL NUMBER OF ENROLLEES SUSPECTED OF FRAUD
AND ABUSE
* The Contractor is required to provide specific explanations of the "other" category with regard to the basis of the dispute.
                                               TABLE OF CONTENTS


                   NETWORK AND HOSPITAL ADEQUACY REPORTING FORMS




                                                        SECTION 6


                                                                                                  Page Number




3.1     Effective Dates and Reporting Time Frames ................................................... 2




Appendix A – Reporting Forms ..............................................................................6




                                                                                                                1
TABLE 1


REPORTING REQUIREMENTS



 Number            Description                                Due Date



Report 1     Network Adequacy Reporting Form        45 business days following
                                                           quarter-end

Report 2     Hospital Adequacy Reporting Form       45 business days following
                                                           quarter-end


Report 3     Out of State Services Reporting Form   45 business days following
                                                           quarter-end




                                                                             2
          Section 6


         Appendix A

Network Adequacy Report Forms




                                3
           Network Adequacy Report


MAINTAIN AN ADEQUATE NETWORK THAT ENSURES THE FOLLOWING:
     PCP-To-Recipient Ratios - Health Plan must
have at least one (1) full-time equivalent (FTE)
primary care provider, considering all lines of
business for that provider, for every one
thousand five hundred (1,500) enrollees per
service area. However, if the PCP practices in
conjunction with a health care professional the
ratio is increased to one (1) FTE PCP for every
one thousand eight hundred (1,800) recipients
per service area.

                                                      Clark County - provider-to-enrollee
                                                      ratio exceeds the contract standard

                                                         # of PCP providers =
                                                         # of enrollees =
                                                         # of providers per 1,500 enrollees =

                                                                Washoe County - provider-to-
                                                      enrollee ratio exceeds the contract
                                                      standard

                                                         # of PCP providers =
                                                         # of enrollees =
                                                         # of providers per 1,500 enrollees =
                                                                Statewide - provider-to-
                                                      enrollee ratio exceeds the contract
                                                      standard

                                                         # of PCP providers =
                                                         # of enrollees =
                                                         # of providers per 1,500 enrollees =
Physician Specialists - Health Plan must provide
access to all types of physician specialists for
PCP referrals, and it must employ or contract
with specialists, or arrange for access to
specialty care outside of Health Plan's network, if
necessary, in sufficient numbers to ensure
specialty services are available in a timely
manner. The minimum ratio for across-the-board
specialists (i.e. those who are not PCPs) is one
(1) specialist per one thousand five hundred
recipients per service area (1:1,500).


                                                      Clark County - provider-to-enrollee
                                                      ratio exceeds the contract standard

                                                         # of Specialist providers =
                                                         # of enrollees =
                                                         # of providers per 1,500 enrollees =



                                                                                                1
            Network Adequacy Report


                                                            Washoe County - provider-to-enrollee
                                                            ratio exceeds the contract standard

                                                               # of Specialist providers =
                                                                   # of enrollees =
                                                               # of providers per 1,500 enrollees =
                                                                      Statewide - provider-to-
                                                            enrollee ratio exceeds the contract
                                                            standard

                                                               # of Specialist providers =
                                                               # of enrollees =
                                                               # of providers per 1,500 enrollees =
     Dentist-To-Recipient Ratios: Health Plan
must have at least one (1) full-time equivalent
(FTE) dentist per one thousand five hundred
(1,500) recipients per geographic service area.
Health Plan’s dental provider network must also
include at a minimum one (1) pediatric dentist,
one (1) dental hygienist, and one (1) oral surgeon.
In clinic practice settings where a dentist
provides direct supervision of dental residents
who have a temporary permit from the State
Board of Dentistry
     in good standing, Health Plan may request and                   Clark County -
DHCFP may authorize the capacity to be increased
as follows: one (1) dental resident per one thousand        1. General Dentist-to-enrollee ratio
(1,000) recipients per Vendor. The dentist shall be         exceeds the contract standard
immediately available for consultation, supervision,
or to take over treatment as needed. Under no                  # of General Dentists =
circumstances shall a dentist relinquish or be                 # of enrollees =
relieved of direct responsibility for all aspects of care      # of providers per 1,500 enrollees =
of the recipients enrolled with the dentist.
                                                            2. All Dental Providers-to-enrollee ratio
                                                            exceeds the contract standard

                                                               # of Dental Providers =
                                                               # of enrollees =
                                                               # of providers per 1,500 enrollees =

                                                            3. Minimum number of required dental
                                                            specialties

                                                               Pediatric dentist =
                                                               Hygienist =
                                                               Oral Surgeon =




                                                                                                        2
           Network Adequacy Report

                                                                  Washoe County -

                                                         1. General Dentist-to-enrollee ratio
                                                         exceeds the contract standard

                                                            # of General Dentists =
                                                            # of enrollees =
                                                            # of providers per 1,500 enrollees =

                                                         2. All Dental Providers-to-enrollee ratio
                                                         exceeds the contract standard

                                                            # of Dental Providers =
                                                            # of enrollees =
                                                            # of providers per 1,500 enrollees =

                                                         3. Minimum number of required dental
                                                         specialties

                                                            Pediatric dentist =
                                                            Hygienist =
                                                            Oral Surgeon =

                                                                   Statewide - 1. General
                                                         Dentist-to-enrollee ratio exceeds the
                                                         contract standard
                                                         # of General Dentists =
                                                         # of enrollees =
                                                         # of providers per 1,500 enrollees =

                                                         2. All Dental Providers-to-enrollee ratio
                                                         exceeds the contract standard
                                                         # of Dental Providers =
                                                         # of enrollees =
                                                         # of providers per 1,500 enrollees =

                                                         3. Minimum number of required dental
                                                         specialties
                                                         Pediatric dentist =
                                                         Hygienist =
                                                         Oral Surgeon =




Twenty-Five (25) Mile Rule - The Vendor must offer
every enrolled recipient a PCP or PCS located within
a reasonable distance from the enrolled recipient’s
place of residence, but in any event, the PCP or PCS
may not be more than twenty-five (25) miles from the
enrolled recipient’s place of residence per NAC
695C.160 without the written request of the recipient.




                                                                                                     3
           Network Adequacy Report

                                                           Clark County - 100 percent of
                                                  the estimated membership falls within
                                                  the access standard

                                                     # of PCP providers =
                                                     # of enrollees =
                                                     # of members without access =
                                                           Washoe County -
                                                     # of PCP providers =
                                                     # of enrollees =
                                                     # of members without access =

Review of Twenty-Five (25) Mile Rule for
Behavioral Health - The Vendor must offer every
enrolled recipient a behavioral health provider
located within a reasonable distance from the
enrolled recipient’s place of residence.
                                                            Clark County

                                                  1. All Providers -

                                                     # of behavioral health providers =
                                                     # of enrollees =
                                                     # of members without access =

                                                  2. Facilities -

                                                     # of behavioral health facilities =
                                                     # of enrollees =
                                                     # of members without access =



 Review of Twenty-Five (25) Mile Rule for                  Washoe County
Behavioral Health - The Vendor must offer every   100 percent of the estimated
enrolled recipient a behavioral health provider   membership falls within the access
located within a reasonable distance from the     standard
enrolled recipient’s place of residence.
                                                     # of behavioral health providers =
                                                     # of enrollees =
                                                     # of members without access =

                                                  2. Facilities - 100 percent of the
                                                  estimated membership falls within the
                                                  access standard

                                                     # of behavioral health facilities =
                                                     # of enrollees =
                                                     # of members without access =




                                                                                           4
            Network Adequacy Report

 Review of Twenty-Five (25) Mile Rule for Behavioral               Statewide1. All Providers -
Health - The Vendor must offer every enrolled
recipient a behavioral health provider located within a   # of behavioral health providers =
reasonable distance from the enrolled recipient’s         # of enrollees =
place of residence.                                       # of members without access =

                                                          2. Facilities -
                                                          # of behavioral health facilities =
                                                          # of enrollees =
                                                          # of members without access =




                                                                                                 5
Out of State Services Report
                    Out of State Services - For each geographic area, report
               number of enrollees who traveled out of state, number of
               trips out of state, and total cost of out of state services.




Clark County
               # of Enrollee sent out of state for medically necessary services =
               # of trips =
               Total cost of out of state services =

Washoe
County
               # of Enrollee sent out of state for medically necessary services =
               # of trips =
               Total cost of out of state services =
Hospital Adequacy Report
                           Hospital-To-Recipient Ratios - For each geographic area, report
                           number of enrollees, number of general hospitals and ratio
                           (enrollee/ hospitals). Report numbers of other facilities.

Clark County
                           # of Enrollees =
                           # of Hospitals =
                           Ratio of Hospitals to Enrollees
                           # of Inpatient Medical Rehabilitation Centers or Specialty Hospitals
                           =
                           # of Intermediate Care Facilities =
                           # of Inpatient Psychiatric Hospitals =
                           # of Mental Health Outpatient Clinics =
                           # of Skilled Nursing Facilities =
                           # of Radiology and Noninvasive Diagnostic Centers =
                           # of Special Clinics =

Washoe County
                           # of Enrollees =
                           # of Hospitals =
                           Ratio of Hospitals to Enrollees
                           # of Inpatient Medical Rehabilitation Centers or Specialty Hospitals
                           =
                           # of Intermediate Care Facilities =
                           # of Inpatient Psychiatric Hospitals =
                           # of Mental Health Outpatient Clinics =
                           # of Skilled Nursing Facilities =
                           # of Radiology and Noninvasive Diagnostic Centers =
                           # of Special Clinics =

								
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