36-2906

36-2906. Qualified plan health services
contracts; proposals; administration

A. The administration shall:

1. Supervise the administrator.

2. Review the proposals.

3. Award contracts.

B. The director shall prepare and issue a request for proposal, including a
proposed contract format, in each of the counties of this state, at least once every five
years, to qualified group disability insurers, hospital and medical service corporations,
health care services organizations and any other qualified public or private persons,
including county-owned and operated health care facilities. The contracts shall specify
the administrative requirements, the delivery of medically necessary services and the
subcontracting requirements.

C. The director shall adopt rules regarding the request for proposal process that
provide:

1. For definition of proposals in the following categories subject to the following
conditions:

(a) Inpatient hospital services.

(b) Outpatient services, including emergency dental care, and early and periodic
health screening and diagnostic services for children.

(d) Laboratory, x-ray and related diagnostic medical services and appliances.

2. Allowance for the adjustment of such categories by expansion, deletion,
segregation or combination in order to secure the most financially advantageous proposals
for the system.

3. An allowance for limitations on the number of high risk persons that must be
included in any proposal.

4. For analysis of the proposals for each geographic service area as defined by the
director to ensure the provision of health and medical services that are required to be
provided throughout the geographic service area pursuant to section 36-2907.

5. For the submittal of proposals by a group disability insurer, hospital and
medical service corporation, health care services organization or any other qualified
public or private person intending to submit a proposal pursuant to this section. Each
qualified proposal shall be entered with separate categories for the distinct groups of
persons to be covered by the proposed contracts, as set forth in the request for
proposal.

6. For the procurement of reinsurance for expenses incurred by any contractor or
member or the system in providing services in excess of amounts specified by the director
in any contract year. The director shall adopt rules to provide that the administrator
may specify guidelines on a case by case basis for the types of care and services that
may be provided to a person whose care is covered by reinsurance. The rules shall
provide that if a contractor does not follow specified guidelines for care or services
and if the care or services could be provided pursuant to the guidelines at a lower cost
the contractor is entitled to reimbursement as if the care or services specified in the
guidelines had been provided.

7. For the awarding of contracts to contractors with qualified proposals determined
to be the most advantageous to the state for each of the counties in this state. A
contract may be awarded that provides services only to persons defined as eligible
pursuant to section 36-2901, paragraph 6, subdivision (b), (c), (d) or (e). The director
may provide by rule a second round competitive proposal procedure for the director to
request voluntary price reduction of proposals from only those that have been tentatively
selected for award, before the final award or rejection of proposals.

8. For the requirement that any proposal in a geographic service area provide for
the full range of system covered services.

9. For the option of the administration to waive the requirement in any request for
proposal or in any contract awarded pursuant to a request for proposal for a subcontract
with a hospital for good cause in a county or area including but not limited to
situations when such hospital is the only hospital in the health service area. In any
situation where the subcontract requirement is waived, no hospital may refuse to treat
members of the system admitted by primary care physicians or primary care practitioners
with hospital privileges in that hospital. In the absence of a subcontract, the
reimbursement level shall be at the levels specified in section 36-2904, subsection H or
I.

D. Reinsurance may be obtained against expenses in excess of a specified amount on
behalf of any individual for system covered emergency or inpatient services either
through the purchase of a reinsurance policy or through a system self-insurance program
as determined by the director. Reinsurance may, subject to the approval of the director,
be obtained against expenses in excess of a specified amount on behalf of any individual
for outpatient services either through the purchase of a reinsurance policy or through a
system self-insurance program as determined by the director.

E. Notwithstanding the other provisions of this section, the system may procure,
provide or coordinate system covered services by interagency agreement with authorized
agencies of this state or with a federal agency for distinct groups of eligible persons,
including persons eligible for children's rehabilitative services through the department
of health services and persons eligible for comprehensive medical and dental program
services through the department.

F. Contracts shall be awarded as otherwise provided by law, except that in no event
may a contract be awarded to any respondent that will cause the system to lose any
federal monies to which it is otherwise entitled.

G. After contracts are awarded pursuant to this section, the director may negotiate
with any successful proposal respondent for the expansion or contraction of services or
service areas if there are unnecessary gaps or duplications in services or service areas.