EXHIBIT 1

ACKNOWLEDGEMENT OF AWARENESS, SERVICES TO BE PROVIDED

TABLE OF CONTENTS

1. ACKNOWLEDGMENT OF AWARENESS

CY2027 Intentions

Future Intentions

2. BACKGROUND

3. ADMINISTRATIVE DUTIES OF CONTRACTOR

Administrative Requirements

D-SNP Plan Benefit Packages (PBPs)

Cost-Sharing and Payment Requirements

Supplemental Benefits

Default Enrollment

FIDE Requirements

4. CLINICAL DUTIES OF CONTRACTOR

Coordination of Care and Services

Information Sharing

Social Determinants of Health (SDOH)

Model of Care (MOC)

5. REPORTING REQUIREMENTS

6. DEFINITIONS

1. ACKNOWLEDGMENT OF AWARENESS

By executing this agreement, the Medicare Advantage Organization (MAO) Contractor acknowledges it is aware of, understands, and agrees to the following:

CY2027 Intentions A. The State implemented the Indiana PathWays for Aging program (PathWays) to replace its

Fee-For-Service (FFS) Long-Term Services and Supports (LTSS) service delivery system for individuals aged 60 and older. The Indiana PathWays for Aging program population is comprised of a significant proportion of dual eligible members. The State views Medicare Advantage Dual-eligible Special Needs Plan(s) (D-SNP(s)) as a critical component of the Indiana PathWays for Aging program, as the State desires to better align and integrate care for dually eligible members.

B. The State values the opportunities for increased integration of care and improved health outcomes that the alignment of Medicaid and Medicare systems provides. A significant investment of State and health plan resources has been made to evolve Indiana dual eligible programs to the current, FIDE SNP status. Not only does the FIDE SNP Indiana PathWays for Aging Dual Care (PathWays Dual Care) set the stage for the strongest population health strategy a state can have for duals, it also increases alignment and increases opportunities for success achieving our Medicaid Managed Long-Term Services and Supports (mLTSS) program goals. The State is committed to supporting the success of our integrated models of care and continuing to advance our model.

C. The State expects the Contractor to refine internal and external communication practices in an appropriate manner as a PathWays Dual Care Plan. This includes, but is not limited to:

The Contractor having internal information sharing procedures updates so that staff in need of information shared at any D-SNP or Managed Care Entity (MCE) meeting, that is relevant for successful D-SNP operations, receive needed updates in a comprehensive and timely manner.

The Contractor will proactively communicate to the State information about changes that stand to impact dual eligibles and/or Medicare processes that impact the Indiana dual eligible population. For example, anything that may impact or delay dual eligible enrollment into your D-SNPs or the addition or sunsetting of other Medicare products the Contractor may offer that also enroll individuals with dual eligibility.

D. The Indiana PathWays for Aging MCEs are required to maintain a fully developed companion D-SNP that operates both CO D-SNP and FIDE SNP Plan Benefit Packages (PBPs) statewide. The State shall only contract with D-SNPs that have an aligned parent company holding a contract under Indiana PathWays for Aging Medicaid and mLTSS program.

E. The State has the right to establish an enrollment freeze for any D-SNP offered under this contract based on regulatory actions taken by the State that are in the best interest of the State.

F. The State will require the continued use of integrated materials as outlined in Section 3.CC and will require the use of an integrated Annual Notice of Change (ANOC) and Member Handbook (Evidence Of Coverage) effective for CY2027.

G. The State is continuing to explore greater consistency with Indiana PathWays for Aging Dual

Care plans PBP structure and will require Contractors to offer four (4) D-SNP PBPs going forward, including two (2) distinct Indiana PathWays for Aging Dual Care PBPs, as specified in Section 3.N.

Future Intentions H. The State will take appropriate action to implement any policy changes necessary to effectuate the most recent CMS regulatory requirements around D-SNPs.

I. The State intends to be a more active partner with the Contractor in determining its supplemental benefit offerings and better capturing the value of supplemental benefits offerings for CY2027 to Indiana members. The State intends to collaborate with the Contractor as they develop D-SNP supplemental benefit offerings to ensure alignment with the State’s supplemental benefit design principles. This includes moving into a review and approval relationship between the State and Contractor prior to CMS supplemental benefit offering submission. The State acknowledges that the details it receives about a D-SNP’s proposed supplemental benefits offerings are subject to this Contract’s confidentiality and non-disclosure provisions, specifically including, without limitation, the supplemental benefits confidentiality and non-disclosure provisions in Exhibit 1, Section 3 (Administrative Duties of Contractor).

J. The State may pursue passive enrollment in accordance with CFR 422.60 (g), if transitioning in any new MCEs and D-SNPs. In this case, the Contractor must work with the State to support passive enrollment.

K. The State is actively working to more comprehensively integrate the State’s quality measurement and improvement strategy across Medicaid MCE and dual eligible programming to align efforts and resources to deliver greater impact.

2. BACKGROUND

FSSA administers the Medicaid program in the State of Indiana under Title XIX of the Social Security Act.

The State partners with the Centers for Medicare and Medicaid Services (CMS) to sponsor MAOs under Title XVIII of the Social Security Act, including D-SNP(s) that arrange for the provision of Medicare services for individuals who are dually eligible for both Medicare and Medicaid benefits pursuant to Titles XVIII and XIX of the Social Security Act.

The Medicare Improvements for Patients and Providers Act of 2008 and its implementing regulations issued by CMS require that the Contractor enters into a contract with the State Medicaid Agency to coordinate benefits and/or services for members of the Contractor’s D- SNP(s) within the State. The Balanced Budget Act of 2018 and its implementing regulations issued by CMS require the Contractor’s D-SNP(s) to maintain a level of integration between Medicaid and Medicare.

The Contractor and the State desire to enter into an arrangement regarding the provision of Medicare benefits by the Contractor’s D-SNPs within the State in an effort to improve the integration and coordination of such benefits as well as to improve the quality of care and reduce the costs and administrative burdens associated with delivering such care.

3. ADMINISTRATIVE DUTIES OF CONTRACTOR

Administrative Requirements A. To support ongoing engagement and commitment to improving integration of Medicare and

Medicaid services for dual eligible individuals in Indiana and to foster increased efficiencies and alignment between Medicare and Medicaid operations, processes, and administration, the State shall require the Contractor to dedicate resources and time to attend and engage in regular, ongoing meetings to build meaningful communication and collaboration between the State and all Indiana D-SNPs.

The Contractor shall designate sufficient resources, time, and personnel to attend, at a minimum the following recurring meetings:

1. Monthly D-SNP/Area Agency on Aging (AAA) Care Coordination Workgroups;

2. Routine D-SNP/State Compliance Updates;

3. Monthly D-SNP/MCE Integration Meeting;

4. D-SNP Member Materials Workgroup; and

5. D-SNP Integrated Performance Improvement Workgroup

The Contractor will also be expected to participate and commit sufficient time and staff for initiatives and projects that support the implementation of State Agency Medicaid Contract (SMAC) requirements. The Contractor shall also attend ad-hoc meetings as requested by the State. The State reserves the right to request and require specific Contractor D-SNP staff members to attend any D-SNP related meetings. The Contractor shall accommodate staff schedules to permit staff attendance and participation in scheduled ad hoc meetings.

It is the expectation of the State that the Contractor has internal processes in place to consistently and comprehensively share information conveyed in meetings with the appropriate staff that have responsibility for D-SNP operations and policy. This includes Contractor’s MCE staff, subcontractors and/or vendors as applicable.

The Contractor is required to have a D-SNP/Dual Care Director. This position is responsible for compliance with Indiana's state-specific SMAC which requires the coordination of Medicare and Medicaid benefits. Key requirements include maintaining the State contracts, implementing the Model of Care (MOC) for care coordination, and ensuring compliance with State-specific regulations. The position serves as a liaison with the State and must participate in State dual care meetings and all-MCE collaboration discussions.

The Contractor shall coordinate with the Medicare and Medicaid Coordination Manager in the Indiana Office of Medicaid Policy and Planning (OMPP) to determine all required meeting participants as well as agenda content, meeting duration, scheduling logistics, and meeting frequency.

B. The Contractor must maintain compliance with all Indiana PathWays for Aging contract requirements in addition to SMAC requirements for the Contractor’s FIDE SNPs to be considered compliant Indiana PathWays for Aging Dual Care plans.

In the event the requirements outlined in this contract differ from those in the Indiana PathWays for Aging contract, the Contractor must follow the contract with the more stringent requirements.

C. The State requires the Contractor to operate and maintain a D-SNP Only H Contract with CMS exclusive to the Indiana D-SNP market that is compliant with 42 CFR 422.107.

D. The State requires that PathWays Dual Care maintain an integrated provider network that has at minimum 80% of the PathWays Medicaid plan network providers in the D-SNP network except for those that are Medicaid only. Should the Contractor fall below the 80% threshold, the Contractor is required to submit monthly network overlap reporting on the template provided by the State until the Contractor has had three (3) consecutive months of 80% or higher. The Contractor must be compliant with PathWays network notification requirements;

the State may pursue noncompliance remedies if the Contractor does not maintain compliance.

The Network Overlap Reporting is due in September, utilizing the template provided by the State.

The Contractor must comply with all requirements in Indiana Health Coverage Programs (IHCP) Bulletin BT202595 regarding required Medicare enrollment for home health agencies.

E. The Contractor is required to outreach at least two (2) times to any full benefit dual eligible member enrolled in its non-D-SNP Medicare Advantage product(s). The purpose of this communication is to provide education about the D-SNP product, benefits of enrolling in the D-SNP, and support on changing plan selection. These communications need to occur prior to the Medicare annual enrollment period with at least one (1) of the communications required to be in writing.

The Contractor is required to report to the State details of outreach efforts made (date, communication mode, messaging and impact analysis that stratify dual populations) by the end of October annually in a format as required by the State, as specified in Section 5. D- SNPs are additionally required to submit their overarching dual-eligible member outreach marketing plans to the State quarterly, as specified in Section 5.A.

F. The Contractor must submit to the State a copy of its required D-SNP training for insurance agents. The training material must be submitted on an annual basis prior to annual agent recertification.

To align with the State’s alignment and integration goals, the State may provide the Contractor with Indiana PathWays for Aging educational material that must be shared with the Contractor’s insurance agent community.

G. The Contractor shall provide “Deemed Continued Eligibility” for six (6) months to maintain the maximum continuity of care for individuals that no longer meet D-SNP eligibility criteria due to a temporary loss of Medicaid eligibility (in accordance with the guidance provided by CMS in its annual Medicare Advantage enrollment and disenrollment guidance documents available at https://www.cms.gov/medicare/enrollment-renewal/managed-care-eligibility-enrollment).

H. To mitigate Medicaid eligibility churn and ensure continuity of care, the Contractor shall actively assist D-SNP members in establishing appropriate and timely Medicaid eligibility or reestablishing Medicaid eligibility for members who temporarily lose it. This shall include but is not limited to:

1. Supporting Contractor staff with direct member interaction—including care management and call center staff—in maintaining the knowledge and capacity to help members connect with Medicaid navigators and; understanding where they can access the Medicaid eligibility application; what members need to know about the State redetermination processes; and the State’s expectations for maintaining Medicaid eligibility;

2. Maintaining knowledge of the State agencies, organizations, requirements, and processes for assessing and determining Medicaid eligibility; how these State entities function and serve Medicaid members in Indiana; and how to connect members to them;

3. Assisting D-SNP members in locating and compiling the necessary information and documentation to establish or reestablish Medicaid eligibility ;

4. Assisting D-SNP members identified by the Contractor as potentially eligible for but not yet enrolled in a Medicare Savings Program (MSP) and contacting the Indiana Division of Family Resources (DFR) in order to have MSP eligibility determined.

The State shall provide the Contractor with education opportunities and training on

Medicaid eligibility processes and requirements. The State reserves the right to establish additional review of Contractor systems, processes, and staff education to assess effectiveness and sufficiency.

I. The Contractor shall include the health plan member ID number on CO D-SNP member ID cards. The Contractor shall not include the Medicaid or Medicare Beneficiary ID number on CO D-SNP member ID cards.

J. The Contractor will verify, prior to enrollment of a potential qualified recipient, the individual’s Medicaid eligibility and other eligibility criteria necessary to accurately assign new enrollees to the correct D-SNP PBP. In particular, the Contractor must verify the individual’s specific category of Medicaid eligibility, age; PathWays eligibility; and Nursing Facility Level of Care (NFLOC) need. The Contractor will provide the State with an electronic submission, in a mutually agreed upon format, of those qualified recipients that have voluntarily enrolled and disenrolled in the Plan. The State shall verify the eligibility of those persons on the submission and return the enrollment information to the Contractor as soon as reasonably possible. For those enrollees who are not determined eligible by the State and for which CMS records indicate that the recipient should be eligible, it will be the responsibility of the Contractor to resubmit the enrollment to the State on the next submission, specifying the retroactive effective date of the enrollment in the Plan. Enrollments are otherwise effective only on a monthly basis, with the eligibility period beginning as of the first day of the month after the enrollment is received.

For the purpose of determining a PBP for which an individual is eligible, individuals meeting NFLOC can be identified via 270/271 file exchange with the State. The Contractor must use the State’s Health Care Eligibility Benefit Inquiry and Response (270/271) Companion Guide as a supplemental resource. The Contractor is required to monitor member NFLOC status changes to effectively move enrolled members into the appropriate FIDE SNP NFLOC/non NFLOC PBP. The State expects plans to move members as quickly as possible into the correct PBP, ideally within two (2) calendar months from the date an NFLOC status change was reflected on the 270/271 file.

In accordance with 42 CFR 422.2, 422.66, 422.107, and applicable CMS Medicare Advantage Enrollment and Disenrollment Guidance, the Contractor acknowledges that individuals enrolled in a CO D-SNP may subsequently become newly eligible for enrollment in a FIDE SNP due to a change in eligibility status.

When an individual becomes newly eligible for the FIDE SNP, the Contractor shall implement procedures to actively facilitate aligned enrollment, including timely identification of eligibility changes, provision of clear and compliant member notices, and education regarding the FIDE SNP as an integrated coverage option. Such outreach shall be conducted in compliance with all applicable Medicare marketing, communication, and beneficiary protection requirements and shall not be coercive or misleading.

Nothing in this section shall be construed to require mandatory enrollment or to limit an individual’s right to decline enrollment in the FIDE SNP; however, the Contractor shall demonstrate good faith operational efforts to promote integrated enrollment consistent with federal policy objectives and State goals for Medicare Medicaid integration.

K. The State has the right to establish an enrollment freeze for any D-SNP offered under this contract based on regulatory actions taken by the State that are in the best interest of the State.

L. The Contractor and the State shall mutually agree on the type and format of any information or materials requested by the State that the Contractor agrees to provide. Before submitting to the State any information or materials that the Contractor regards as proprietary or confidential, the Contractor shall label all such information and materials as proprietary and confidential.

1. MCEs and D-SNPs must add “CONFIDENTIAL” to the end of the file name.

2. Example of HPMS file name: H9999_HUM_UnableReach_v1_CONFIDENTIAL

3. Example of Salesforce file name:

999999IN012726_ANT_UnableReach_v1_CONFIDENTIAL

The State shall make good faith, reasonable efforts to establish, implement and enforce policies and procedures governing the receipt, maintenance and storage of, and access to any information and materials labeled by the Contractor as proprietary and confidential pursuant to this contract and to limit access to such information and materials to only those staff members with a direct need for that access. The parties acknowledge and agree that, to the extent that information and materials the Contractor provides to the State contain or constitute trade secrets and/or confidential financial information, such information and materials are excepted from disclosure, inspection and copying pursuant to Indiana Code § 5-14-3-4(a).

M. The following is a list of deliverables the Contractor is required to produce in addition to the formal reports listed in Section 5 (Reporting Requirements). This list is meant to support State and Contractor organization and is not exhaustive. The Contractor must follow all requirements of the contract, and the State may adjust the below list at any time.

● Required D-SNP agent training materials (Section 3.F)

● Submission of pre-enrollment Medicaid eligibility information for potentially qualified recipients (Section 3.J)

● Unified grievance and appeal information, as requested by the State (Section 3.BB.2)

● Integrated member materials for State review within the timeframes established by the State (Section 3.CC.1)

● Written care coordination policies for each PBP (Section 4.E)

● Dementia Care Program Plan, including Dementia Caregiver Support Program

(Section 4.O)

● Falls Prevention Plan (Section 4.P)

● All required training content and strategies for D-SNP care managers (Section 4.Q)

● Submission of required notifications and information related to High-Risk members

(Section 4.S and Section 4.X)

● SDOH assessment tool (Section 4.DD)

● SDOH Interventions Plan (Section 4.FF)

● D-SNP Model of Care (Section 4.GG)

● If applicable, I-SNP and/or C-SNP MOCs (Section 4.MM)

D-SNP Plan Benefit Packages (PBPs) N. The State requires D-SNPs to offer four (4) D-SNP PBP’s that meet the following requirements:

1. CO D-SNP PBP available to full-benefit dual eligible individuals that are not eligible for the Indiana PathWays for Aging program (QMB-Plus, SLMB-Plus, Other Full- Benefit Dually Eligible (FBDE));

2. CO D-SNP PBP available to partial-benefit dual eligible individuals (QMB-only, SLMB-only, QI, QDWI).

3. FIDE SNP PBP available to Indiana PathWays for Aging Dual Care members that are not eligible for Nursing Facility Level of Care (non NFLOC), which include QMB-Plus, SLMB-Plus, and other FBDE members. The State will continue to require FIDE SNP

PBP(s) that must be branded as Indiana PathWays for Aging Dual Care (PathWays Dual Care). Each FIDE SNP PBP shall use Indiana PathWays for Aging Dual Care or PathWays Dual Care as part of the PBP name.

4. FIDE SNP PBP available to Indiana PathWays for Aging Dual Care members that are NFLOC (PathWays Waiver enrollees, Money Follows the Person (MFP) participants, and long-term Nursing Facility residents), which include QMB-Plus, SLMB-Plus, and other FBDE members. The State will continue to require FIDE SNP PBP(s) that must be branded as Indiana PathWays for Aging Dual Care (PathWays Dual Care). Each FIDE SNP PBP shall use Indiana PathWays for Aging Dual Care or PathWays Dual Care as part of the PBP name.

O. In the event that a member who is ineligible for an Indiana PathWays for Aging Dual Care PBP becomes eligible for one of the FIDE SNP PBPs during the contract year, the State expects the Contractor to actively work with the member to support enrollment into the most appropriate PBP that aligns with eligibility status, ideally within two (2) months from the date the individual qualified for enrollment into a FIDE SNP PBP. For any member that cannot be moved within two (2) months of eligibility effective dates, the D-SNP must work with CMS to crosswalk the member into the appropriate PBP for the following calendar year.

P. In the event that a member in a PathWays Dual Care PBP becomes ineligible due to eligibility change, the State expects the Contractor to actively work with the member to support enrollment into the CO D-SNP PBP that aligns with eligibility status, ideally within two (2) months from the date the individual lost FIDE SNP PBP eligibility. For any member that cannot be moved within two (2) months of eligibility effective dates, the Contractor must work with CMS to crosswalk the member into the appropriate PBP for the following calendar year.

Cost-Sharing and Payment Requirements The below section outlines cost-sharing coverage in Indiana. The State of Indiana pays for all dual eligible’s premiums according to the table below, regardless of Medicaid delivery system.

The State of Indiana also covers Medicare Parts A & B cost-sharing (according to the table below) for members in FFS Medicaid. Medicare Parts A & B cost-sharing for members enrolled in Indiana PathWays for Aging are the responsibility of those Medicaid MCEs.

Category Medicare Part A Premiums

Medicare Part B Premiums

Medicare Cost- Sharing

Other Medicaid Benefits

QMB-Only X X X QMB-Plus X X X X

Other FBDE X X* X SLMB-Only X SLMB-Plus X X* X

QI X

QDWI X

*Cost-sharing coverage for SLMB-Plus and Other FBDE members is limited to services covered by IHCP, Medicare covered services not covered by IHCP are not included. QMBs receive cost -sharing coverage on all Medicare covered services, regardless of IHCP coverage of the service.

NOTE: Indiana’s Medicaid State Plan Section 3.2 outlines the cost-sharing coverage for members with Medicare. As required by Federal Law, QMB members (with or without full Medicaid) cannot be billed for any cost-sharing for Medicare Part A or Part B services. The above table is only for Medicare Parts A and B; Part D is not included.

Q. Indiana does not allow any nominal Medicaid copayments to be charged to the population(s) eligible for enrollment in the Contractor’s D-SNP under its state plan for medical assistance.

Therefore, per sections 1902(n)(3)(B) and 1852(a)(7) of the Social Security Act and 42 CFR 422.504(g)(1)(iii), the Contractor may not charge any QMB, QMB+, SLMB+ or Other FBDE enrollee of the Contractor’s D-SNP any cost sharing for any Medicare A or B service rendered by one of the Contractor’s network providers, except in the rare case of Medicare A or B services that are not covered under Indiana’s Medicaid state plan or an Indiana Medicaid waiver, wherein SLMB+ and Other FBDE enrollees in the Contractor’s D-SNP may be charged the full Medicare cost-sharing amount specified within the D-SNP’s PBP. SLMB, QI, and QDWI enrollees are responsible for covering their own cost-sharing amounts for Medicare A and B services.

The Contractor’s materials shall:

Clearly describe the cost-sharing amounts corresponding to each Part A and B service covered under the Contractor’s D-SNP and the enrollee populations to whom those cost-sharing amounts apply (specifically, the D-SNP’s SLMB, QI, and QDWI enrollees).

Make clear that QMB and QMB+ enrollees will not owe any Medicare cost-sharing amounts for any Medicare A or B services rendered by a provider in the Contractor’s network or an out-of-network provider enrolled in Medicare.

Make clear that SLMB+ and Other FBDE enrollees will not be held liable for cost -sharing amounts associated with Medicare A and B services rendered by the Contractor’s network providers if the services are also covered under Indiana’s Medicaid state plan.

[For PPOs and HMO-POS plans only] Indicate that SLMB+ and Other FBDE individuals may be charged cost-sharing amounts if they see a provider who is not part of the Contractor’s D-SNP network or a registered Medicaid provider in Indiana, and/or obtain services that are not covered under Indiana’s Medicaid state plan or an Indiana Medicaid waiver.

The Contractor’s provider agreements shall specify that:

For services rendered to QMB and QMB+ enrollees, contracted providers will: (1) accept the Contractor’s Medicare reimbursement as payment in full or bill the MCE or State, as applicable, for any additional Medicare cost-sharing payments that may be reimbursable by Medicaid, and (2) refrain from collecting any cost sharing from the QMB or QMB+ enrollees.

For services rendered to the Contractor’s SLMB+ and Other FBDE enrollees, contracted providers will accept the Contractor’s Medicare reimbursement as payment in ful l or bill the MCE or State, as applicable, for services that are covered under Indiana’s Medicaid state plan or an Indiana Medicaid waiver, and refrain from collecting cost sharing from SLMB+ and Other FBDE enrollees for those services.

For services rendered to SLMB, QI and QDWI enrollees, contracted providers will charge the enrollees no more than the cost-sharing amounts established within the Contractor’s

D-SNP PBP.

R. The Contractor shall recognize limits on the out-of-pocket costs for the dual-eligible persons enrolled in its Plans. The Contractor shall not impose cost-sharing requirements on dual-eligible Plan members that would exceed the amounts permitted under Medicaid regulations.

S. Medicaid is required by federal regulations to access all third-party payment sources and to seek reimbursement for services that have also been paid by Medicaid. “Third Party” means an individual, institution, association, corporation or public or private agency, including Medicare, private health insurance and workers compensation insurance that is liable for payment of all or part of the medical cost of injury, disease or disability of a Medicaid beneficiary. The Contractor shall cooperate with the State’s efforts to enforce third party liability, including procedures for appropriate coordination of benefits between Medicare and Medicaid. Medicare benefits, including those offered by the Contractor through its Plans, will sometimes pay after third party resources other than Medicaid and nothing in this Contract shall prevent the Contractor from enforcing its rights regarding payments of and by any non- Medicaid third party.

To ensure the State does not duplicate payments on any provided services, the D-SNP will provide a copy of its CMS submitted SNP bid to the State within thirty (30) days of submission to CMS. The D-SNP will provide a copy of the D-SNP's approved CMS bid to the State if the approved bid differs significantly from the submitted bid. The D-SNP must identify information as trade secret prior to or at the time of its submission for the State to consider classifying such trade secret data as non-public.

Supplemental Benefits T. The Contractor shall collaborate with the State on its supplemental benefit offerings and the development process for its supplemental benefit offerings in order to achieve the goals outlined in Section 1.I of the “Acknowledgement of Awareness” in this contract and to align with member benefits offered through Indiana Medicaid [supplemental benefits are defined under 42 CFR 422.102 and in Chapter 4, Section 30 and Chapter 16b, Sections 20.2.6.1 – 3 of the Medicare Managed Care Manual found at https://www.cms.gov/Regulations -and- Guidance/Guidance/Manuals/Downloads/mc86c04.pdf and https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/mc86c16b.pdf respectively] .

The State has outlined four (4) key principles that the Contractor should use when designing supplemental benefit offerings:

1. Ensure D-SNPs are offering additional benefits that are both population specific and provide extra value to the Indiana PathWays for Aging Dual Care program,

2. Prioritize benefit designs that fill gaps in current benefit structures and support FSSA-identified clinical goals,

3. Simplify supplemental benefit offerings (remove/reduce duplication of coverage for services already covered by Medicaid & Medicare), and

4. Design D-SNP supplemental benefits to support FSSA dual eligible population health priorities while innovating to meet member needs.

U. The Contractor must submit the following reports specific to supplemental benefits:

1. Proposed Supplemental Benefit Offering Report (due March 15th). The State will provide feedback to the D-SNPs by the end of the first week of April,

2. Finalized Supplemental Benefit Offering Report (due by the end of the first week of September), and

3. Supplemental Benefit Summary Document (due by the end of the first week of September).

The State will provide timely review and approval of supplemental benefit offerings prior to when the Contractor is to file benefits with CMS, in a timeline that aligns with Contractor Medicare bid development work. The State will continue to gather Contractor feedback regarding the updated process and timelines to minimize administrative burden.

Default Enrollment V. All Indiana PathWays for Aging Dual Care D-SNPs must obtain approval from the CMS to be able to default enroll members enrolled in its aligned Indiana PathWays for Aging Medicaid MCE. In conformance with 42 CFR 422.66(c), 422.68(a) and other CMS-published sub-regulatory guidance, as applicable, PathWays Dual Care D-SNPs shall perform the default enrollment process for individuals already enrolled in its parent company's Indiana PathWays for Aging Medicaid plan who are newly eligible for Medicare Parts A and B for the first time due to age or disability. The State reserves the right to activate or deactivate default enrollment based on plan performance at any time but will coordinate with the affected D- SNP for transition.

W. In the event that the Contractor receives returned mail from a default enrollment eligible member then the Contractor must make a minimum of three (3) call attempts to the member regarding their default enrollment eligibility.

X. The Contractor must maintain a minimum STAR rating of three (3) and may not have any prohibition on new enrollment imposed by CMS as outlined under 42 CFR 422.66(c) in order to participate in default enrollment. The State shall provide the Contractor with the information necessary to identify those Indiana Medicaid categorically eligible members who are or will be in their Medicare initial coverage election period during the term of the Contract. At least monthly, the State will use the CMS TBQ and MMA files to identify Affiliated Medicaid MCE members with prospective Medicare Parts A and B eligibility due to age or disability. For the affiliated Medicaid MCE members identified by the State, the State will provide the following information to the Contractor monthly in a proprietary file format via a secure file transfer protocol (SFTP) site no less than seventy (70) days before an affiliated Medicaid MCE member becomes eligible for Medicare Parts A and B due to age or disability:

1. First and last name

2. Medicare Parts A and B entitlement date

3. Date of birth

4. MBI

5. Gender

Y. The Contractor must establish an internal process to validate information shared on the Default

Enrollment Extract sent from the State. The Contractor shall supplement information provided by the State where appropriate in order to enroll, to the greatest extent possible, all members included in the Default Enrollment Extract.

Z. The Contractor must also take the necessary steps to renew any existing default enrollment process approval(s) with CMS, as per the requirement of 42 CFR 422.66(c)(2)(ii ). To minimize the risk of disruption in default enrollment processing, the Contractor shall submit renewal applications to CMS well in advance of the current approved end dates. CMS notifies the MAO six (6) months before the expiration of default enrollment approval. The Contractor shall submit their renewal application within sixty (60) days of receiving CMS expiration notification. The Contractor is required to notify the State within five (5) business days of receiving CMS expiration notice. The Contractor shall provide the following information in their notification to the State:

1. Date by which the Contractor intends to submit a default enrollment application to CMS.

Application must be within sixty (60) days from receiving CMS expiration notice.

2. Date by which the Contractor intends to submit application documents to the State for review and request data sharing process. The Contractor is expected to give the State at least thirty (30) days to complete review of the application documents. Documents must be submitted to the State within thirty (30) days after receiving CMS expiration notice.

3. The expected date by which the Contractor will begin to mail the 60-day advance Notice to Confirm Default Enrollment to impacted members after application is approved.

The State expects the default enrollment application to be approved at least sixty (60) days prior to the currently approved application. The Contractor is required to notify the State of any deviations to this timeline within two (2) business days of identifying potential delay.

FIDE SNP (PathWays Dual Care D-SNP) Requirements AA. Exclusively Aligned Enrollment

a. Exclusively aligned enrollment (EAE) limits the PathWays Dual Care D-SNP’s membership to individuals whose Medicare and Medicaid benefits are provided under a single entity. Federal and Indiana policy requires all PathWays Dual Care FIDE SNPs to operate with EAE. PathWays Dual Care FIDE SNPs with EAE qualify as an applicable integrated plan (AIP), as defined and governed by 42 CFR 422.561.

b. Under the terms of this Agreement, enrollment into the Contractor’s PathWays Dual Care D-SNP will be limited to only those full benefit dual eligible members who are enrolled with the Contractor’s companion Indiana PathWays for Aging MCE, and who maintain such plan enrollment throughout the course of their PathWays Dual Care D- SNP enrollment. The PathWays Dual Care D-SNP shall keep a member in its PathWays Dual Care D-SNP for the required 6-month deeming period in accordance with this Agreement if such member loses Medicaid eligibility and can reasonably be expected to regain such eligibility within six (6) months.

c. The PathWays Dual Care D-SNP agrees to conduct enrollment of eligible members in accordance with this Agreement and must maintain EAE for the duration of the contract period. The Contractor is required to incorporate language provided by the State into the Enrollment form.

d. The PathWays Dual Care D-SNP shall provide to the State enrollment reports every year in accordance with the timing and format established by the State to ensure that the EAE process is being implemented appropriately.

BB. Unified Grievances and Appeals

1. The PathWays Dual Care D-SNP must comply with the unified grievance and appeal procedures described under the terms of 42 CFR 422.629 – 42 CFR 422.634, 42 CFR 438.210, 42 CFR 438.400, and 42 CFR 438.402. This includes:

i. Grievance and appeal systems that meet the standards described in 42 CFR 422.629;

ii. An integrated grievance process that complies with 42 CFR 422.630;

iii. A process for making integrated organization determinations consistent with 42

CFR 422.631;

iv. Continuation of benefits while an integrated reconsideration is pending consistent with 42 CFR 422.632;

v. A process for making integrated reconsiderations consistent with 42 CFR

422.633; and

vi. A process for effectuation of decisions consistent with 42 CFR 422.634.

2. The State may request unified grievance and appeal data or information from final CMS audit reports. For any corrective actions issued by CMS for unified grievances and appeals, the PathWays Dual Care D-SNP shall notify the State within fifteen (15) days of receipt from CMS.

i. The State reserves the right to request ad hoc data and records from the PathWays Dual Care D-SNP separate from any requests from or submissions to

CMS.

ii. In addition to Medicare requirements enumerated at 422.629(h)(2), the PathWays Dual Care D-SNPs shall adhere to any additional requirements for recordkeeping outlined in the PathWays MCE contract and are subject to comply with any changes that occur in the stated section of the PathWays MCE contract, particularly any requirements not captured in CMS reporting.

3. To operationalize and maintain the unified grievance and appeal process, the PathWays Dual Care D-SNP must ensure alignment between the PathWays and PathWays Dual Care D-SNP grievance and appeal processes, including alignment in timeframes for notices, responses, and resolutions. The PathWays Dual Care D-SNP will operationalize the processes and corresponding timeframes specified below to ensure compliance with both 42 CFR 422 and 423 Subpart M for Medicare and Section 5.14 of the PathWays Scope of Work and 2024 Indiana Code Title 27. Insurance Article 1. Department of Insurance Chapter 37.5. Health Care Service Prior Authorization 27-1-37.5-11:

Requirement FIDE SNP Timeline

Routine Grievances- acknowledgement letter

Three (3) business days

Expedited Grievance and Medicare Fast Complaints

Resolved and responded to within twenty-four (24) hours.

No acknowledgement letter required

Appeal acknowledgement The Contractor must acknowledge receipt of each standard appeal within three (3) business days

Expedited Appeal Resolved within forty-eight (48) hours

Coverage Decision Letter

Letter notification must be sent within seven (7) calendar days after the date the service request was received

Integrated Organization Determinations/ Coverage Determinations- timing of plan decisions

Letter notification must be sent within seven (7) calendar days after the date the service request was received

4. The PathWays Dual Care D-SNP, as an applicable integrated plan as defined in 42 CFR

422.561, is required to use the CMS-provided model for the Coverage Decision Letter to be issued to members as a result of an integrated organization determination for a service or item (including a Part B drug) that is not resolved fully in favor of the member, as described under 42 CFR 422.631. The State reserves the right to require PathWays Dual Care D-SNPs to use other CMS-provided model materials to support the integrated grievance and appeal process.

5. When populating the Coverage Decision Letter with plan-specific information, the PathWays Dual Care D-SNP must refer to its single member services/customer service phone number as described in Section 3.DD.

6. The Contractor shall have processes in place where the assigned care coordinator, service coordinator, and/or case manager are notified of integrated appeal processes outcomes to support effective care coordination activities.

CC. Member Materials

Integrated Member Materials

1. The Contractor is required to submit integrated member materials to the State for review within the timeframes established by the State. The State intends to leverage the joint review process in HPMS for integrated materials as well as for other specified materials and reserves the right to review Medicaid information in D-SNP member materials outside of the HMPS joint review process when necessary. The Contractor may be required to make State-requested changes to integrated member materials upon the State’s review. Required integrated materials will include the following, and as specified in the CMS/Indiana-provided templates, the Contractor must also post an online version of the integrated Provider and Pharmacy Directory and integrated Formulary on its website:

i. A single ID card for accessing all PathWays Dual Care D-SNP and PathWays Plan services and benefits provided under the PathWays Dual Care D-SNP PBP and as outlined in the PathWays Contract.

1. The State may require the Contractor to include the State issued Medicaid State ID number or an approved integrated ID number for the PathWays Dual Care Member ID Card.

2. The ID card must include a single member services/customer service phone number as described in Section 3.DD.

3. The ID card must be co-branded displaying the State issued PathWays Dual Care logo.

ii. A combined Provider and Pharmacy Directory that includes all Providers of PathWays Dual Care D-SNP and PathWays MCE services and benefits, and as stated in the Directory, requires the member to choose a Medicare Primary Care Provider (PCP) which will be primary over any Medicaid provider.

iii. A Formulary (List of Covered Drugs) that includes Outpatient Prescription Drugs (including both Generic and Name Brand) that are covered under Medicare, Medicaid, or as PathWays Dual Care D-SNP-covered supplemental benefits, and what Tier each medication is on.

iv. A Summary of Benefits that include Medicare and Medicaid covered benefits.

v. An integrated Annual Notice of Change (ANOC) document.

vi. A Member Handbook (EOC).

2. Regarding required integrated member materials, including all written member notices required for the unified grievance and appeal process, the PathWays Dual Care D-SNP shall adhere to the requirements of both 42 CFR 422 Subpart V for Medicare and requirements outlined in the PathWays MCE contract.

i. The Contractor is required to reference the Indiana Long-Term Care (LTC) Ombudsman resource, as defined in Section 6 Definitions, on relevant member notices, as applicable.

Other Member Materials

3. The Contractor is required to submit other member materials to the State for review per the State’s established approval process. Other member materials include, but are not limited to, quarterly member newsletters, materials promoting health, materials regarding preventative care information, and member reminders to complete health screenings.

The Contractor may be required to make State-requested changes.

DD. Integrated Customer Service

1. The Contractor shall be responsible for establishing a single member services/customer service phone number for current dual eligible enrollees to contact the Contractor regarding their PathWays Dual Care D-SNP, PathWays MCE, and benefits. Members must be able to access one line that is directly answered by a single, trained, live representative who is either:

i. Knowledgeable about the PathWays program, Medicare, and the terms of this Agreement, including covered services and available care coordination, or

ii. Able to conduct at most, one warm transfer for the member to another live representative or live resource that is knowledgeable about the PathWays program, Medicare, and the terms of this Agreement, including covered services and available care coordination.

2. If a plan must answer first with an automated answering tree, such process shall provide amongst its initial choices the option of speaking with a live representative that, when selected, takes the caller directly to the live representative described in Section 3.DD.1.

i. Live representatives must be provided access to the PathWays Dual Care D- SNP enrollee database and an electronic provider directory. In addition to Medicare customer service call center requirements and standards as outlined in 42 CFR 422.111(h), and as described in the Medicare Communications and Marketing Guidelines (MCMG), the single member services/customer service phone number shall adhere to member toll-free call center requirements as outlined in the PathWays contract, with the Contractor subject to comply with any changes that occur in the stated section of the PathWays contract. The PathWays Dual Care D-SNP shall adhere to the more member-protective requirements in instances where Medicare requirements at 42 CFR 422.111(h) conflict with sections referenced in the PathWays contract.

4. CLINICAL DUTIES OF CONTRACTOR

Coordination of Care and Services A. The Contractor will have a process in place which assists providers, family members or others who are calling the D-SNP requesting identification of a member’s current case coordinator and/or care manager and contact information, with proper member consent. This process must be efficient and not require the callers to make multiple phone calls to find the requested information.

B. The Contractor will make available to Medicaid qualified recipients (“Qualified Recipients”) who have Medicare Part A and Part B coverage and reside in the counties listed in Exhibit 2 of this contract, a health insurance policy (the “Plan”) providing benefits as outlined in the Contractor’s Medicare Advantage health benefit plan. For those who enroll in the Contractor’s D-SNP, the Contractor shall be responsible for coordinating the Plan benefits with the Medicaid covered services applicable to their PBP. For PathWays Dual Care members, this includes coordination and full management of the services set forth in ATTACHMENT B to this Exhibit 1, INDIANA PATHWAYS FOR AGING BENEFITS.

C. The Contractor shall assist members in coordinating all needed Medicaid services, facilitating access to those services, and arranging for the provision of such services through identification and referral to participating Medicaid providers—including long-term services and supports (LTSS) and home and community-based service (HCBS) providers—in its provider network and within its approved service area as listed in Exhibit 2 of this Contract.

This includes proactively identifying members before they become 60 years of age and assisting them in transitioning to PathWays Dual Care and the PathWays Waiver when applicable.

D. The Contractor shall be responsible for providing care coordination for all Medicare and Medicaid services for all members including those the State has designated as High-Risk.

For the purposes of this contract, FSSA defines a High-Risk member as any member of the CO D-SNP PBP available to full-benefit dual eligible individuals that are not eligible for the Indiana PathWays for Aging program (QMB-Plus, SLMB-Plus, Other FBDE) who is currently enrolled in the Health and Wellness (H&W), Community Integration and Habilitation (CIH), or Family Supports (FS) HCBS Waiver or Money Follows the Person HCBS programs.

E. The Contractor shall develop separate written care coordination policies for each PBP: Indiana PathWays for Aging Dual Care (NFLOC PBP and non-NFLOC PBP) non-PathWays Full Duals PBP, and Partial Duals PBP within the MOC submission. Written care coordination policies and amendments for any contract year shall be submitted to FSSA for review at least one hundred and twenty (120) days prior to January 1 of the contract year.

The Contractor shall incorporate the care coordination policies developed under this Section in its D-SNP MOC which shall be reviewed and approved as part of the State’s MOC review process. The State shall work in good faith with the Contractor on the most efficient and effective incorporation of this information in its MOC and other relevant plan documents as indicated in Section 4.GG of this contract.

The Contractor shall ensure that its MOC appropriately reflects updated care coordination standards/requirements corresponding to the changes in coordinating care with the Indiana PathWays for Aging MCEs. The D-SNP will submit the MOC to the State with associated care coordination policies and procedures as evidence of implementation of Indiana PathWays for Aging requirements.

F. The Contractor shall assume primary responsibility for care coordination of aligned PathWays members including a designated D-SNP care coordinator (distinguished from D-SNP care manager terminology to be used for non-PathWays D-SNP members) and fully integrated Health Risk Assessment (HRA), Individualized Care Plan (ICP), Interdisciplinary Care Team (ICT), and Care Transition protocols. The Indiana PathWays for Aging Dual Care PBP(s) will provide all covered Medicare benefits to meet or exceed care coordination standards as detailed in the PathWays Scope of Work and include:

a. PathWays stratification to complex care management including but not limited to PathWays Dual Care…