ANÁLISIS DE IMPACTOS AMBIENTALES Y SOCIALES

The Contractor shall have an office located within eighty (80) miles of Frankfort, Kentucky within thirty (30) days of contract execution. Prior to October 1, 2011 such office shall, at a minimum, provide for the following staff functions:

A. Executive Director for the Kentucky account B. Member Services for Grievances and Appeals

C. Provider Services for Provider Relations and Enrollment

Other functions required to be available may be located outside of an eighty (80) mile radius of Frankfort, Kentucky.

The Contractor may subcontract for any functions; however, the above functions, if subcontracted, shall be approved by the Department and shall be carried out within an eighty (80) mile radius of Frankfort, Kentucky. All Subcontractors shall meet appropriate licensing and contract requirements specified in applicable State and Federal laws and regulations.

10.1 Administration/Staffing

The Contractor shall provide the following functions that shall be staffed by a sufficient number of qualified persons to adequately provide for the member enrollment and services provided. Responsibility for these functions or staff positions may be provided by, combined with or split among Contractor’s departments, people or Subcontractors and carry such titles as Contractor designates and provides to the Department. The

Executive Management shall be capable and responsible for the oversight of the entire operation.

A. An Executive Director who is to act as liaison to the Department for all issues that relate to the Contract between the Department and the Contractor. The Executive Director shall act as the primary contact and will be authorized to represent the Contractor regarding inquiries pertaining to the contract, will be available during normal business hours, and will have decision-making authority in regard to urgent situations that arise. The Executive Director will be responsible for follow-up on contract inquiries initiated by the Department.

B. A Compliance Director whose responsibilities shall be to ensure financial and programmatic accountability, transparency and integrity. The Compliance Director shall maintain current knowledge of Federal and State legislation, legislative initiatives, and regulations relating to Contractor and oversee the Contractor’s compliance with the laws and Contract requirements of the Department. The Compliance Director shall also serve as the primary contact for and facilitate communications between Contractor leadership and the Department relating to Contract compliance issues. The Compliance Director shall also oversee Contractor implementation of and evaluate any actions required to correct a deficiency or address noncompliance with Contract requirements as identified by the Department.

C. A Medical Director who shall be a Kentucky-licensed physician. The Medical Director shall be actively involved in all major clinical programs and Quality Improvement components. The Medical Director shall devote sufficient time to ensure timely medical decisions, including after-hours consultation as needed.

D. A Dental Director who shall be a dentist licensed by a Dental Board of Licensure in any state. The Dental Director shall be actively involved in all major dental programs. The Dental Director shall devote sufficient time to ensure timely dental decisions, including after-hours consultation as needed.

An internal auditor shall ensure compliance with adopted standards and review expenditures for reasonableness and necessity.

F. A Member Services Director and function to coordinate all communications with Members and act as Member advocates. This function shall include sufficient Member Services staff to respond in a timely manner to Member seeking prompt resolution to their problems or inquiries.

G. A Provider Services Director and function to coordinate all communications with Contractor’s providers and Subcontractors. This function shall include sufficient Provider Services staff to respond in a timely manner to Providers seeking prompt resolution to their problems or inquires.

H. A Quality Improvement Director who shall be responsible for the operation of the Contractor’s QAPI Program and any QAPI Program of its subcontractors.

I. A Guardianship Liaison who shall serve as the Contractor’s

primary liaison for meeting the needs of Members who are adult guardianship clients.

J. A Case Management Coordinator who shall be responsible for coordination and oversight of case management services and continuity of care for the Contractor’s Members.

K. An Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Coordinator who shall coordinate and arrange for the provision of EPSDT services and EPSDT special services for Members.

L. A Foster Care/Subsidized Adoption Liaison who shall serve as the Contractor’s primary liaison for meeting the needs of Members who are children in foster care and subsidized adoptive children. M. A Management Information System Director and function who

shall oversee, manage and maintain the Contractor’s management information system (MIS).

N. A Behavioral Health Director who shall be a behavioral health practitioner and actively involved in all programs or initiatives relating to behavioral health. The Behavioral Health Director shall also coordinate efforts to provide behavioral health services by the Contractor or any behavioral health subcontractors.

O. A Pharmacy Director who shall coordinate, manage and oversee the provision of pharmacy services to Members.

P. A Claims Processing Director and function who shall ensure the timely and accurate processing of original Claims, corrected Claims, re-submissions and overall adjudication of Claims.

Q. A Program Integrity Coordinator who shall coordinate, manage and oversee the Contractor’s Program Integrity unit to reduce fraud and abuse of Medicaid Services.

The Contractor shall submit to the Department on annual basis and upon request by the Department, a current organizational chart depicting all functions including mandatory functions, number of employees in each functional department and key managers responsible for the functions. The Contractor shall notify the Department in writing of any staffing change in the Executive Director, Finance Director, Medical Director, Pharmacy Director, Dental Director, Behavioral Health Director, Compliance Director or Quality Improvement Director positions within ten (10) business days. The Commonwealth reserves the right to approve or disapprove all key personnel (initial or replacement) prior to their assignment with the Contractor. The Contractor shall ensure that all staff, Providers and Subcontractors have appropriate training, education, experience, liability coverage and orientation to fulfill the requirements of their positions.

Contractor shall provide notice to the Department of any changes relating to the personnel of its management staff, including a change in duties or time commitments. Contractor shall assure the adequacy of its administrator’s staffing to properly service the needs of Contractor if changes are proposed in the personnel, duties or time commitments of administrator’s staff from those in place on the Effective Date of each Contract. Contractor shall provide those assurances to the Department before permitting its administrator to implement such changes.

11. Capitation Payment Information