240000001363.pdf

STATE OF MICHIGAN PROCUREMENT

Department Technology, Management and Budget Central Procurement Services 320 S Walnut Street Lansing, MI 48933 P.O. Box 30026, Lansing, MI 48909

CONTRACT CHANGE NOTICE

Change Notice Number 5 to Contract Number MA240000001363

C O

N

TR

A C

TO

R

AETNA BETTER HEALTH OF

MICHIGAN

2 Towne Square, Suite 275

Southfield MI 48076

Teressa Smith

313-465-1548

SmithT26@aetna.com

CV0003449

ST

A

TE

Pr og ra m

M an ag er

Jennifer Therrien MDHHS

517-284-1145

TherrienJ1@michigan.gov

C on tr ac t A dm in is tr at or Marissa Gove DTMB

(517) 449-8952 govem1@michigan.gov

CONTRACT SUMMARY

Comprehensive Health Care Program – DHHS (Regions 7, 8, 9, 10)

INITIAL EFFECTIVE DATE

October 1, 2024

INITIAL EXPIRATION DATE

September 30, 2029

INITIAL AVAILABLE OPTIONS

3 - 1 Year

EXPIRATION DATE

BEFORE

September 30, 2029

PAYMENT TERMS

Net 45

DELIVERY TIMEFRAME

N/A

ALTERNATE PAYMENT OPTIONS

P-Card Direct Voucher (PRC) Other

EXTENDED PURCHASING

Yes No

MINIMUM DELIVERY REQUIREMENTS

N/A

DESCRIPTION OF CHANGE NOTICE

OPTION LENGTH OF OPTION EXTENSION LENGTH OF EXTENSION REVISED EXP. DATE

CURRENT VALUE

$6,825,507,200.00

VALUE OF CHANGE NOTICE

$0.00

ESTIMATED AGGREGATE CONTRACT VALUE

$6,825,507,200.00

DESCRIPTION

Please note the Program Manager or Contract Administrator may have changed, and are reflected on this Change Notice.

Effective January 28, 2026, this Contract is amended in accordance with the attached revisions. All other terms, conditions, specifications and pricing remain the same. Per contractor and agency agreement, and DTMB Central Procurement approval.

CHANGES EFFECTIVE OCTOBER 1, 2025

1. Schedule A, Statement of Work Appendix 23 Capitation Rate Certification is hereby deleted and replaced in its entirety with the following:

Medicaid Health Plan Capitation Rate Certification

The Medicaid per member per month rates effective October 1, 2025 are located in the link below.

SFY 2026 Medicaid Managed Care Certification

October 2025 CHCP Rate Certification Amendment https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Assistance-Programs/Medicaid-BPHASA/Other-Prov-Specific-Page-Docs/DRAFT-SFY-2025-Medicaid-Managed-Care-Certification.pdf?rev=e96030d708cc4198bb58a5811cd0293f&hash=6B5627DE32C9C1E266CAB56000083735 https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Assistance-Programs/Medicaid-BPHASA/Other-Prov-Specific-Page-Docs/October-2025-CHCP-Rate-Certification-Amendment.pdf?rev=951be5c308f34c08b31ae241d2b8b418&hash=53990B7DDF475F2DF4AB15E268590C2D

320 S Walnut Street Lansing, MI 48933 P.O. Box 30026, Lansing, MI 48909

STATE OF MICHIGAN PROCUREMENT

Department Technology, Management and Budget Central Procurement Services

CONTRACT CHANGE NOTICE

CONTRACT SUMMARY

Comprehensive Health Care Program – DHHS (Regions 7, 8, 9, 10)

INITIAL EFFECTIVE DATE INITIAL EXPIRATION DATE INITIAL AVAILABLE OPTIONS EXPIRATION DATE

BEFORE

October 1, 2024 September 30, 2029 3 - 1 Year September 30, 2029

PAYMENT TERMS DELIVERY TIMEFRAME

ALTERNATE PAYMENT OPTIONS EXTENDED PURCHASING

MINIMUM DELIVERY REQUIREMENTS

N/A

P-Card Direct Voucher (PRC) Other Yes No

2 Towne Square, Suite 275

Southfield MI 48076

Teressa Smith

313-465-1548 smitht26@aetna.com

CV0003449

AETNA BETTER HEALTH OF

MICHIGAN

C O

N

TR

A C

TO

R

517-284-1145

TherrienJ1@michigan.gov

Marissa Gove

(517) 449-8952

DTMB

Jennifer Therrien MDHHS govem1@michigan.gov

C on tr ac t A dm in is tr at or

Pr og ra m

M an ag er

ST

A

TE

N/ANet 45

Change Notice Number 4

Contract Number MA240000001363 to

DESCRIPTION OF CHANGE NOTICE

OPTION EXTENSIONLENGTH OF OPTION LENGTH OF EXTENSION REVISED EXP. DATE

CURRENT VALUE VALUE OF CHANGE NOTICE ESTIMATED AGGREGATE CONTRACT VALUE

0 Years

$6,825,507,200.00 $0.00 $6,825,507,200.00

DESCRIPTION

Please note the Program Manager or Contract Administrator may have changed, and are reflected on this Change Notice.

Effective November 10, 2025, this Contract is amended in accordance with the attached revisions. All other terms, conditions, specifications and pricing remain the same. Per contractor and agency agreement, and DTMB Central Procurement approval.

CHANGES EFFECTIVE OCTOBER 1, 2025

1. Schedule A, Statement of Work Section 1.1, III. A. Value-Based Payment Models (3.) and (4.) are hereby added in its entirety, (3.) and (4.) are hereby renumbered to (5.) and (6.), (5.) and (6.) are hereby deleted and replaced in its entirety with the following:

3. Contractor must ensure that all incentive payment contracts between the Contractor and network providers meet the requirements as specified in 42 CFR 438.3(i)(3) and (4), including the following:

a. Have a defined performance period that can be tied to the applicable MLR reporting periods

b. Be signed and dated by all appropriate parties before the commencement of the applicable performance period

c. Include clearly defined, objectively measurable, and well documented clinical or quality improvement standards that the provider must meet to receive the incentive payment

d. Specify a dollar amount or a percentage of a verifiable dollar amount that can be clearly linked to successful completion of the metrics defined in the incentive payment contract, including a date of payment.

4. Contractor must make the incentive payment contracts with network providers and any other incentive payment documentation required by MDHHS, available to MDHHS upon request.

5. As directed in Appendix 5F, Contractor will report to MDHHS on MHP health care service reimbursement under value-based contracts using the format specified by MDHHS in Appendix 5F and will comply with payment reform goals and threshold targets established by MDHHS in consultation with contracted MHPs.

6. Contractor in accordance with timeliness requirements outlined in Appendix 5F must submit its APM Reports including:

a. APM Strategic Plan PowerPoint

b. APM Data Collection Tool

c. APM Quality Impact Analysis

d. APM Dental

2. Schedule A, Statement of Work

Section 1.1, III. C. Mental Health Integration (2.) is hereby deleted and replaced in its entirety with the following:

2. Contractor must work with MDHHS to develop and implement initiatives to:

a. Improve coordination of physical health and mental health services covered by Contractor,

b. Improve coordination of services covered by Contractor and the Prepaid Inpatient Health Plan(s)

(PIHP) serving Contractor’s Enrollees, and

c. Provide incentives that advance the integration and coordination of physical health and mental health care at the clinical level.

3. Schedule A, Statement of Work Section 1.1, IV. O. Medicaid Health Plan Billing Issues and Complaint Resolution (2a.) is hereby deleted and replaced in its entirety with the following:

a. Within 48 hours of receipt of a complaint, Contractor must provide MDHHS with an update on the resolution process or a description of resolution.

4. Schedule A, Statement of Work Section 1.1, V. A. Network Requirements (7.) is hereby deleted and replaced in its entirety with the following:

7. Contractor must ensure its network of contracted Providers offers an appropriate range of preventive care, primary care, mental health care, and specialty care to meet the needs of all Enrollees including Enrollees in CSHCS and PSHCN and submit documentation to MDHHS to that effect.

5. Schedule A, Statement of Work Section 1.1, V. C. Network Access Plan (6a.) is hereby deleted and replaced in its entirety with the following:

a. Offers an appropriate range of preventive, primary care, specialty, mental health, dental and NEMT services, in accordance with this Contract, that is adequate for the anticipated number of Enrollees for the Service Area.

6. Schedule A, Statement of Work Section 1.1, V. L. Child and Adolescent Health Centers (3.) is hereby deleted and replaced in its entirety with the following:

3. To promote early intervention of mental health conditions among children and adolescents, Contractor must support the MDHHS CAHC mental health services initiative.

a. Contractor must take steps to ensure adequate network access to mental health services to address mild to moderate mental health needs of child and adolescent Enrollees.

b. Contractor must contract with MDHHS designated CAHC organizations who meet the minimum Medicaid Eligibility rate as determined by MDHHS, for increased access to behavior health services for youth 5 through 21 years of age.

c. Contractor must comply with MDHHS guidance related to payer partner participation in the CAHC initiative including but not limited to:

i. Sharing data and exchanging health information;

ii. Submission of CAHC utilization reports as directed by MDHHS; and

iii. Making payments according to the CAHC Initiative payment to participating CAHC organizations as determined and instructed by MDHHS.

7. Schedule A, Statement of Work

Section 1.1, V. M. Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) (3.)

is hereby deleted and replaced in its entirety with the following, and (3.-5.) are hereby renumbered to (4.-6.):

3. For contracted clinics that are applying for certification as an FQHC or RHC, the date of certification as an FQHC or RHC by either CMS or HRSA shall serve as the effective date for MHP enrollment and payment of FQHC and RHC services.

8. Schedule A, Statement of Work

Section 1.1, V. O. Children’s Multidisciplinary Specialty (CMDS) Clinics (1.) is hereby deleted and replaced in its entirety with the following:

O. Children’s Multidisciplinary Specialty (CMDS) Clinics and Children with Medical Complexity (CMC) Targeted Case Management (TCM)

1. Contractor must establish and maintain a coordination agreement with each CMDS clinic/facility and/or CMC TCM program to ensure coordinated care planning and data sharing, including but not limited to the assessment and treatment plan.

9. Schedule A, Statement of Work Section 1.1, VI. B. Services Covered Under this Contract (1kk.) is hereby added in its entirety with the following, and (kk.-oo.) are hereby renumbered to (ll.-pp.):

kk. Substance use treatment services provided by healthcare providers in an office-based setting not enrolled or associated with a PIHP, consistent with MDHHS guidance (MMP 23-61)

10. Schedule A, Statement of Work

Section 1.1, VI. B. Services Covered Under this Contract (3.) and (4.) are hereby deleted and replaced in its entirety with the following:

3. Preventive Healthcare Services

a. Enrollees will have no cost share liability for preventive care services exempt from such liabilities in Medicaid Policy and in accordance with the Medicaid State Plan.

4. Substance Use Disorder in an Inpatient Hospital Setting

a. Contractor shall provide coverage of substance use disorder SUD consult services provided for the expert assessment, evaluation, diagnosis, and treatment of individuals during a medically indicated hospital encounter with a co-occurring SUD.

11. Schedule A, Statement of Work

Section 1.1, VI. D. Pharmacy Services (18a.) is hereby deleted and replaced in its entirety, and (35.)

and (36.) are hereby added in their entirety with the following:

a. Contractor must meet the 97% SPDL preferred utilization rate for the period of October 1, 2025 through September 30, 2026.

35. The MHP or its subcontractors shall not utilize a drug discount benefit card as part of their pharmacy benefit.

36. Contractor's reimbursement methodology for their pharmacy benefit should not exceed FFS allowed reimbursement for dispensing fees and allowed ingredient costs, except for pharmacies that are subject to the provisions of Public Act 279 of 2023.

12. Schedule A, Statement of Work https://content.govdelivery.com/attachments/MIDHHS/2023/12/06/file_attachments/2707545/Final%20Bulletin%20MMP%2023-61-OBSUT.pdf

Section 1.1, VI. E. Emergency Services (11.) and (11a.) are hereby renumbered to (10b.) and (10c.), and (12.) is hereby renumbered to (11.).

13. Schedule A, Statement of Work Section 1.1, VI. H. Non-Emergency Medical Transportation (6b.) is hereby deleted and replaced in its entirety and (13a.) and (13b.) are hereby added in their entirety with the following:

6b. Services for MIHP, or other MDHHS approved evidence-based home-visiting program, enrolled pregnant and infant beneficiaries to access health care and pregnancy-related appointments and for a mother to visit their hospitalized infant. Pregnancy-related appointments include those for oral health services, WIC services, mental health or substance use disorder treatment services, and childbirth and parenting education classes.

13a. For children aged 12 to 18, a consent letter from a parent, guardian, or caregiver is needed for unaccompanied transportation, unless parental consent is not required by the Medicaid Program.

13b. Parental consent is not required for children who are emancipated or those seeking certain healthcare services they can legally consent to and do not need a consent letter. These services include care related to pregnancy, sexually transmitted infections (STIs), HIV/AIDS, substance use disorders, or outpatient care from Community Mental Health Service Programs (CMHSP).

14. Schedule A, Statement of Work Section 1.1, VI. M. Mental Health Benefit is hereby deleted and replaced in its entirety with the following:

M. Mental Health Benefit

1. Contractor must provide mental health care consistent with Appendix 7 and MDHHS Policy.

a. Contractor shall work with MDHHS to prepare for future changes to coverage responsibility for mental health services, including but not limited to expanding the mental health benefit under this Contract.

b. MDHHS is developing a new benefit plan called “BH-COVER”, that, effective October 1, 2026, will indicate whether the Contractor or the Enrollee’s PIHP is responsible for coverage of each Enrollee’s mental health care. Contractor is prohibited from using this benefit plan to make coverage-related determinations prior to October 1, 2026, however, as MDHHS continues to develop and test this benefit plan. MDHHS may pursue contract remedies including but not limited to monetary sanctions and other sanctions, such as corrective action, in the event Contractor is found to be using the new benefit plan to inform service coverage, authorization, and payment or other determinations.

2. Contractor may provide mental health services through contracts with PIHPs, CMHSP providers, and other mental health Providers, as needed to ensure adequate access to all mental health services covered under this Contract. Contractor shall take steps to partner with CMHSPs operating in their Service Area to provide covered mental health services.

15. Schedule A, Statement of Work Section 1.1, VI. R. Cell and Gene Therapy is hereby added in its entirety with the following:

R. Cell and Gene Therapy Contractor must ensure that Enrollees participating in the Cell and Gene Therapy Access Model have access to the providers that administer their gene therapy treatment for at least 365 days after infusion.

16. Schedule A, Statement of Work

Section 1.1, VIII. A. General is hereby deleted and replaced in its entirety with the following:

A. General

1. Dental services for all Enrollees under age 21 (except HMP enrollees age 19 and 20)

2. Services provided by a school district and billed through the Intermediate School District

3. Mental Health services covered by PIHPs, pursuant to MDHHS policy and Appendix 7, including but not limited to:

a. Inpatient psychiatric services provided at an inpatient psychiatric hospital or in an inpatient psychiatric bed or unit within an acute care hospital (see Appendix 7)

b. Emergency intervention services and post-crisis stabilization services (see Appendix 7)

c. Mental health services for Enrollees with Serious Mental Illness (SMI) or (Serious Emotional Disturbance (SED) (see Appendix 7)

4. Certain substance use disorder (SUD) services , in accordance with Appendix 7and MMP 23-61, including:

a. SUD assessment services that are not provided by “primary healthcare providers” as defined in

MMP 23-61

b. Intensive outpatient counseling and other outpatient services that are not provided by “primary healthcare providers” as defined in MMP 23-61

c. Methadone treatment and other SUD treatment that is not provided by “primary healthcare providers” as defined in MMP 23-61

d. Detoxification (see Appendix 8)

5. Services, including but not limited to therapies (speech, language, physical, occupational), provided to persons with intellectual and/or developmental disabilities (I/DD) that are billed through PIHPs, CMHSP providers, or Intermediate School Districts

6. Intermittent or short-term restorative or rehabilitative services (in a nursing facility), after disenrollment

7. Custodial care in a nursing facility

8. Home and Community-Based Waiver Program services

9. Personal care or home help services

17. Schedule A, Statement of Work Section 1.1, VIII. A. Access to Services for Enrollees with Mental Health Needs (1b.), (2.), (2a.) is hereby deleted and replaced in its entirety, (3) is hereby added in its entirety with the following, and (3.) is renumbered to (4):

1b. Contractor must provide information to PCPs on when and how to refer Enrollees to mental health Providers within Contractor’s network, PIHPs and PIHP Network Providers, in accordance with the MDHHS-specified format, process, and timeline, as outlined in Appendix 22.

2. Mental Health Care

a. Contractor must ensure access to all mental health services covered under this Contract to all Enrollees with mental health needs, in accordance with the Medicaid Provider Manual and the Medicaid Mental Health and Substance Use Disorder Authorization and Payment Responsibility Grid available in Appendix 7.

i. MDHHS reserves the right to modify the Medicaid Mental Health and Substance Use Disorder Authorization and Payment Responsibility Grid, including but not limited to changing coverage responsibility for mental health services so that responsibility will be determined by the level of Enrollees’ needs rather than by the setting in which a service is provided.

ii. Contractor may not require prior authorization for assessment of mental health need, as described in Section 1.1VIII.A.3. below.

Contractor shall partner with MDHHS in readiness activities related to changes in mental health coverage responsibility at MDHHS direction.

3. Assessment of Mental Health Need

a. Contractor must ensure that Qualified Mental Health Providers, as defined below, in its Provider Network utilize the State’s designated tools, as appropriate, for assessing the level of mental health need of Enrollees seeking mental health services, in accordance with Appendix 21.

i. The State’s designated tools for assessing mental health need include:

i. The Michigan Child and Adolescent Needs and Strengths (MichiCANS) Screener for infants, toddlers, children, youth, and young adults.

ii. The Level of Care Utilization System (LOCUS) for adults.

ii. The following categories of providers are Qualified Mental Health Providers provided that assessment of mental health need is within their scope of practice:

i. Qualified Mental Health Professionals, as defined in the Medicaid Provider Manual and in DEFINITIONS.

ii. Child Mental Health Professional, as defined in the Medicaid Provider Manual and in DEFINITIONS.

iii. Qualified Intellectual Disabilities Professionals, as defined in the Medicaid Provider Manual and in DEFINITIONS.

iii. Contractor must ensure that Qualified Mental Health Providers in its Provider Network:

i. Complete all initial and ongoing training necessary to administer and complete the State-designated tools for assessing mental health need listed in Section 1.1.VIII.A.3.a.i.

ii. Complete an assessment of mental health needs for the Enrollees they serve using the State’s designated tools listed in Section 1.1.VIII.A.3.a.i annually or upon a change in Enrollee condition.

iii. Submit information on these assessments to MDHHS, as specified by MDHHS, within 24 hours of completing the assessment.

b. Contractor shall work with MDHHS and its Network Providers to ensure mental health assessments as described in this section are being completed in accordance with Appendix 21. This includes but is not limited to:

i. Supporting Qualified Mental Health Providers in Contractor’s Provider Network in understanding and complying with assessment requirements described in Appendix 21. This may include reporting information to MDHHS, upon MDHHS request.

ii. Notifying Qualified Mental Health Providers when annual assessments are due for Enrollees they have historically served.

iii. Completing ongoing fidelity monitoring of the use of the State-designated tools listed in Section 1.1.VIII.A.3.a.i, which may involve collecting information from Network Providers.

18. Schedule A, Statement of Work Section 1.1, VIII, B. Collaboration with PIHPs (1b.), is hereby deleted and replaced in its entirety, (1c.)

is hereby added in its entirety, (1c.) and (1d.) are hereby renumbered to (1d.) and (1e.), (4.) is hereby deleted and replaced in its entirety, (5b.) is hereby deleted and replaced in its entirety, and (8.) is hereby deleted and replaced in its entirety, with the following:

1b. Contractor must establish a designated point of contact to coordinate referrals for mental health services with Coordinating PIHPs and PIHP network providers. The Contractor’s designated point of contact must:

1c. For all PIHPs in the Contractor’s service area, Contractor must maintain record of the PIHP designated point(s) of contact for mental health referrals and share that information with mental health and Primary Care Providers in the Contractor’s Provider Network at least annually, whenever updates are made, and upon request from the Provider.

4. Referrals between Contractor and PIHPs/PIHP Network Providers.

When referring an Enrollee to a PIHP or PIHP Network Provider for mental health services:

a. Contractor must utilize the format, process, and timeline specified by MDHHS, consistent with policies reflected in Appendix 22.

b. Contractor must act on all referrals it receives from PIHPs and PIHP Network Providers in accordance with the MDHHS-specified process and timelines, as described in Appendix 22.

c. Contractor must ensure its Network Providers:

i. Utilize the MDHHS-specified format, process, and timeline when referring Enrollees to PIHPs or PIHP Network Providers for mental health services, in accordance with Appendix 22.

ii. Act on referrals they receive from PIHPs and PIHP Network Providers in accordance with the MDHHS-specified process and timelines, as described in Appendix 22.

d. Contractor must share referral information received from a PIHP or PIHP Network Provider with the Enrollee’s PCP and any other Providers delivering ongoing treatment or services to the Enrollee, consistent with consent and privacy standards outlined elsewhere in this Contract.

e. Contractor must utilize the MDHHS-specified platform to track Enrollee referrals between Contractor and the PIHP delivery system, in accordance with Appendix 22, and conduct follow-up as needed to endure Enrollee is able to access services timely. This should include referrals for Enrollees not engaged in Contractor’s care management programs as well as referrals originating at the Provider level. Such follow-up may include, but is not limited to, outreach to the originating Provider, the Enrollee’s PIHP and PIHP Network Provider, and/or the Enrollee to determine status of and facilitate completion of pending referrals, consistent with Appendix 22.

f. Contractor must establish and follow protocols to ensure Enrollees being referred to or from a PIHP or PIHP Network Provider have continuous access to any needed medication and treatment during the period of referral. It is the responsibility of the Contractor to ensure Enrollees do not lose access to necessary medication and treatment during the referral period, which ends when the Enrollee establishes care under a PIHP Network Provider or Contractor Network Provider

g. Contractor must participate in MDHHS efforts to facilitate information sharing between MHPs and PIHPs. Contractor shall work with MDHHS and Network Providers to:

i. Support Network Providers in understanding and complying with MDHHS’ requirements relating to mental health referrals across MHP and PIHP delivery systems.

ii. Complete ongoing monitoring relating to mental health referrals across MHP and PIHP delivery systems.

5b. Child and adolescent Enrollees (age 20 and younger) who have significant mental health issues and complex physical comorbidities are, at a minimum, Enrollees who meet the following criteria:

i. Have received one or more PIHP service in the prior six (6) months;

ii. Have two or more emergency department (ED) visits within the prior six

(6) months; and

iii. Have diagnoses of one or more of any of the following physical health chronic conditions:

i. Asthma

ii. Cystic Fibrosis

iii. Congenital Heart Disease

iv. CNS Congenital Malformation

v. Cerebral Palsy

vi. Cerebral Palsy Paralytic Syndromes

vii. Diabetes

viii. Hepatitis-C

ix. HIV

x. Essential Hypertension

xi. Obesity

xii. Rheumatoid Arthritis Osteoarthritis

xiii. Sickle Cell Disease

xiv. Seizure Epilepsy

xv. Congenital Syphilis

8. Emergency Intervention Services. To facilitate coordinated care for Enrollees experiencing a crisis, Contractor must:

h. Establish policies and procedures with Coordinating PIHPs and with Emergency Intervention Services Providers to receive timely notification of any Enrollee utilizing Emergency Intervention Services.

i. Within 2 business days of receipt of notification of Emergency Intervention Service utilization, identify and provide to the PIHP or the Emergency Intervention Services provider who notified the Contractor of the service utilization with up-to-date contact information for the following:

i. Any provider of care management services, Peer-Support Specialist and/or Community Health Worker serving the Enrollee;

ii. The Enrollee’s PCP; and

iii. Any other Provider(s) that deliver ongoing treatment or services to the Enrollee, if applicable.

j. Notify the Providers described above (Section 1.1.VIII.B.8.b.) of the Enrollee’s utilization of Emergency Intervention Services consistent with consent and privacy standards.

k. Document the Enrollee’s utilization of Emergency Intervention Services and communication with the PIHP and PIHP Network Provider(s) in the Contractor’s electronic data system (Section 1.1.XVI.B).

19. Schedule A, Statement of Work

Section 1.1, X. B. Addressing Health Disparities (3a.) is hereby deleted and replaced in its entirety with the following:

3a. Contractor must enter into two or more agreements with Community-based Organizations (CBOs) in each Region the Contractor serves to support Population Health improvement strategies supported by evidence-based medicine and national best practices in the Contractor’s Region, including efforts addressing Social Determinants of Health. Such agreements should include at least one of, but are not limited to, the following activities: referring Enrollees to community-based Social Services to meet health and Health Related Social Needs, providing services to meet Health Related Social Needs, coordinating Social Services between settings and other providers, tracking and reporting on outcomes of referral to address Health Related Social Needs, and assisting members in applying for public benefit programs (SNAP, TANF, WIC, utility and weatherization programs) including through use of MI Bridges, as needed.

Contractor agrees to comply with SDOH-focused CBO agreement requirements provided by MDHHS.

Agreements must address:

20. Schedule A, Statement of Work

Section 1.1, X. D. Providing Care Management Services and Other Targeted Interventions (1c.) is hereby deleted and replaced in its entirety and (1i.(vii)) is hereby added in its entirety as follows:

1c. Contractor must offer a robust care management program that meets NCQA and/or URAC accreditation standards to Enrollees who qualify for care management services, and other subpopulations as designated by MDHHS, including but not limited to disabled populations, high-risk pregnancies, and populations with chronic conditions, Enrollees in CSHCS, children in foster care, former foster care youth in Foster Care Transitional Medicaid, and Cell and Gene Therapy (CGT) recipients. When determining additional Enrollees to offer robust care management services, Contractor should consider Health Related Social Needs, including but not limited to: housing, food/nutrition and non-medical transportation.

1i.(vii.)) Contractor must implement interventions to improve Continuous Glucose Monitoring (CGM) utilization for disparate populations and report to MDHHS, at least annually, using MDHHS provided template.

21. Schedule A, Statement of Work

Section 1.1, X. E. In Lieu of Services (2a.), (2a.ii.(i.1.)), (2a.ii.(i.3.)), (2a.ii.(ii.)), (2a.iii.(i.1.)), (2a.iii.(ii.)), and (2a.iv.(i.1.)) are hereby deleted and replaced in their entirety with the following:

2a. Contractor may offer Enrollees one or more of the following approved Nutrition ILOS. In accordance with general prohibitions on payment for room and board under title XIX of the Social Security Act, food interventions provided through ILOS must be less than three (3) meals per day. These ILOS are further described in Appendix 20.

2a.ii.i.1. Has a nutrition-sensitive condition, including diabetes, cardiovascular disorders, congestive heart failure, stroke, chronic lung disorders, hypertension, HIV, cancer, obesity, oral health disease, sickle cell disease, malnutrition, renal disease or a mental health and substance use disorder;

2a.ii.i.3. Has been identified by the Contractor to be at risk of an avoidable emergency department visit, hospital admission or institutionalization;

2a.ii.ii. Effective January 1, 2026, the Contractor shall use or require the use of the HCPCS Code S5170 with the modifier “V2” to indicate that a Healthy Home Delivered Meal was provided.

2a.iii.i.1. Has a nutrition-sensitive condition, including diabetes, cardiovascular disorders, congestive heart failure, stroke, chronic lung disorders, hypertension, HIV, cancer, obesity, oral health disease, sickle cell disease, malnutrition, renal disease or a mental health and substance use disorder;

2a.iii.ii. Effective January 1, 2026, the Contractor shall use or require the use of the HCPCS Code S9977 with the modifier “V2” to indicate that a healthy food pack was provided.

2a.iv.i.1. Has a nutrition-sensitive condition, including diabetes, cardiovascular disorders, congestive heart failure, stroke, chronic lung disorders, hypertension, HIV, cancer, obesity, oral health disease, sickle cell disease, malnutrition, renal disease or a mental health and substance use disorder;

22. Schedule A, Statement of Work Section 1.1, XI. A. Quality Assessment and Performance Improvement (QAPI) Program (5d.) is hereby added in its entirety and (5d.) is hereby renumbered to (5e.) with the following:

5d. Incorporate and address the goals and objectives, including specific quality metrics, outlined in MDHHS’s Comprehensive Quality Strategy.

23. Schedule A, Statement of Work

Section 1.1, XI. E. External Quality Review is hereby deleted and replaced in its entirety with the following:

E. External Quality Review Activities

1. Contractor must take all steps necessary to support the External Quality Review Organization (EQRO) contracted by MDHHS to conduct External Quality Review (EQR) activities, in accordance with 42 CFR 438.358. Contractor must participate fully and completely with all EQR-related activities as specified by MDHHS and/or federal regulations.

2. Contractor must develop and implement performance improvement goals, objectives, and activities in response to the findings from EQR activities as part of Contractor’s QAPI program or other improvement plan document as appropriate. Improvement plans related to PIPs, CAHPS, and PMV EQR activities must be included in QAPI program.

3. MDHHS may also require separate submission of an improvement plan specific to the findings of the EQRO.

4. EQR activities will include, but are not limited to the following:

a. Validation of performance measures

b. Validation of provider network adequacy, including conducting Secret Shopper Surveys

c. Validation of encounter data reported by Contractor to MDHHS

d. Validation of performance improvement projects required by MDHHS

e. Development of annual Consumer Guide and/or Quality Rating

f. Review of compliance with, at a minimum, standards set forth in 42 CFR 438 subpart D, the disenrollment requirements and limitations described in 42 CFR 438.56, the enrollee rights requirements described in 42 CFR 438.100, the emergency and post-stabilization services requirements described in 42 CFR 438.114, and the quality assessment and performance improvement requirements described in 42 CFR 438.330.

5. Contractor must take all steps necessary to support the EQRO in conducting EQR activities including, but not limited to:

a. Designating a qualified individual to serve as project lead for each EQR activity who must, at a minimum, perform the following activities:

i. Oversee and be accountable for compliance with all aspects of the EQR activity;

ii. Coordinate with staff responsible for aspects of the EQR activity and ensure that staff respond to requests by the EQRO or MDHHS staff in a timely manner;

iii. Serve as the liaison to the EQRO and MDHHS and answer questions or coordinate responses to questions from the EQRO and MDHHS in a timely manner; and

iv. Ensure timely access to information systems, data, and other resources, as necessary for the EQRO to perform the EQR activity and as requested by the EQRO or MDHHS.

b. Maintaining data and other documentation necessary for completion of EQR activities specified above. Contractor must maintain such documentation for a minimum of ten (10) years;

c. Reviewing the EQRO’s draft reports, if requested, and offering comments and documentation to support the correction of any factual errors or omissions, in a timely manner, to the EQRO or MDHHS;

d. Participating in Contractor-specific and cross-contractor meetings relating to the EQR process, EQR findings, and/or EQR trainings with the EQRO and

MDHHS;

e. Implementing actions to address recommendations for improvement made by the EQRO or MDHHS, and sharing outcomes and results of such activities with the EQRO or MDHHS; and

f. Participating in any other activities deemed necessary by the EQRO and approved by MDHHS.

24. Schedule A, Statement of Work

Section 1.1, XI. I. Utilization Management (5.) is hereby deleted and replaced in its entirety with the following:

5. Contractor’s authorization policy must establish timeframes for standard and Expedited Authorization Decisions.

a. These timeframes may not exceed 14 Days from date of receipt for Standard Authorization Decisions and 72 hours from date of receipt for Expedited Authorization Decisions. Effective January 1, 2026, authorization decisions may not exceed seven (7) calendar days to review Standard Authorization Decisions and 72 hours from receipt for Expedited Authorization Decisions.

b. For cases in which a Provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, the Contractor must make an Expedited Authorization Decision and provide notice as expeditiously as the Enrollee’s health condition requires and no later than 72 hours after receipt of the request for service.

c. These timeframes may be extended up to 14 additional Days if:

i. The Enrollee, or the Provider, requests extension; or

ii. The Contractor justifies (to the State agency upon request) a need for additional information and how the extension is in the Enrollee’s interest. The Enrollee must be notified in writing of the plan’s intent to extend the timeframe.

d. Contractor must notify the requesting provider and give the Enrollee written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. Enrollee notice must meet the requirements of 42 CFR 438.404.

e. Beginning January 1, 2026, Contractor must report prior authorization data from the preceding calendar year, excluding data on any drugs covered by the Contractor, by March 31 of each year in accordance with 42 CFR 438.210 (f). Contractor must make the following data from the previous calendar year publicly accessible by posting them on its website:

i. A list of all items and services that require prior authorization;

ii. The percentage of standard prior authorization requests that were approved, aggregated for all items and services;

iii. The percentage of standard prior authorization requests that were denied, aggregated for all items and services;

iv. The percentage of standard prior authorization requests that were approved after appeal, aggregated for all items and services;

v. The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services;

vi. The percentage of expedited prior authorization requests that were approved, aggregated for all items and services;

vii. The percentage of expedited prior authorization requests that were denied, aggregated for all items and services;

viii. The average and median time that elapsed between the submission of a request and a determination by the Contractor for standard prior authorizations, aggregated for all items and services;

ix. The average and median time that elapsed between the submission of a request and a determination by the Contractor for expedited prior authorizations, aggregated for all items and services.

25. Schedule A, Statement of Work

Section 1.1, XI. J. Lead Monitoring (4.) is hereby added in its entirety with the following:

4. Contractor must enter into an agreement with all Local Health Departments (LHDs) to coordinate care for children with Elevated Blood Lead Level (EBLL) Nursing Case Management in Contractor’s service area.

a. Contractor must use most recent version of MHP LHD EBLL Care Coordination Agreement as provided by MDHHS.

b. Contractor must execute new agreements or amendments at the direction of

MDHHS.

26. Schedule A, Statement of Work

Section 1.1, XIII. H. Grievance and Appeal Process for Enrollees (2b.) is hereby deleted and replaced in its entirety with the following:

2b. Contractor must mail the Adverse Benefit Determination notice within the timeframes specified in 42 CFR 438.404(c).

27. Schedule A, Statement of Work

Section 1.1, XIV. E. Provider Credentialling and Recredentialling is hereby deleted and replaced in its entirety with the following:

Contractor must comply with the requirements of MCL 500.3528 and 42 CFR 438.214 regarding the credentialing and recredentialing of Providers within the Contractor’s Provider Network, including but not limited to the requirements specified in this section. Contractor must implement written policies and procedures for selection and retention of Network Providers that meet uniform credentialing and recredentialing policies established by MDHHS. Contractor must follow a documented process for credentialing and recredentialing of Network Providers.

MDHHS intends to standardize the credentialing and recredentialing process. Contractor acknowledges MDHHS’ intent and commits to participating in activities necessary to ensure the successful implementation of a standardized credentialing process, including but not limited to: stakeholder engagement initiatives, implementation planning activities, and compliance with current and future MDHHS credentialing policies and processes.

28. Schedule A, Statement of Work

Section 1.1, XIV.F. Payment to Providers (1c.) and (1e.) are hereby deleted and replaced in its

1c. Clean Claim means all claims as defined in 42 CFR 447.45, MCL 400.111i, and DIFS Bulletin 2000-09.

1e. Contractor must ensure that the date of receipt is the date the Contractor receives the claim, as indicated by its date stamp on the claim; and that the date of payment is the date of the check or other form of payment.

29. Schedule A, Statement of Work

Section 1.1, XV. E. Provider Network File (4275) (4.) is hereby deleted and replaced in its entirety with the following:

4. The 4275 file must contain all contracted Providers, unless specified otherwise by MDHHS.

30. Schedule A, Statement of Work

Section 1.1, XVI. B. Electronic Exchange of Client-Level Information (3.) is hereby deleted and replaced in its entirety, and (7.) is hereby added in its entirety with the following:

3. Contractor must ensure LHDs, CMDS clinics, and CMC TCM programs that provide and coordinate services for Enrollees in CSHCS have the ability to exchange real-time client-level information for the purpose of care management and coordination.

7. Contractor must engage in preparation activities related to APIs, so that by January 1, 2027, requirements of the Interoperability and Prior Authorization Final Rule (CMS-0057-F) are met.

31. Schedule A, Statement of Work

Section 1.1, XVIII. D. Compliance with False Claims Acts (1a.) is hereby deleted and replaced in its entirety with the following:

1a. If the Contractor should delegate any contractual requirement (or any process that lends to a contractual requirement) relating to the detection and prevention of Fraud, Waste and Abuse to a subcontractor or agent, it is the Contractor’s responsibility to maintain a contract agreement that outlines the specific program integrity responsibilities and/or maintain written policies and procedures that reiterate the conditions of this Contract.

32. Schedule A, Statement of Work Section1.1, XIX. Program Integrity is hereby deleted and replaced in its entirety with the following:

The MDHHS Office of Inspector General (OIG) is responsible for overseeing the program integrity activities of the Michigan Medicaid Health Plans consistent with this Contract and the requirements under 42 CFR 438.608.

All requirements in this section of the contract must be supported by Contractor internal policies and procedures to demonstrate implementation and compliance.

Late program integrity submissions of any type, including but not limited to Compliance Reviews, corrective action plans (CAPs), and/or audit results, may be subject to contract remedies such as sanctions and/or liquidated damages.

33. Schedule A, Statement of Work Section1.1, XIX. A. Fraud, Waste and Abuse (1a.(ii.)) is hereby added in its entirety and (1a.(ii.) is renumbered to (1a(iii.)) with the following:

Conflict of Interest – Contractor will uphold high ethical standards and is prohibited from holding or acquiring an interest that would conflict with this Contract. Contractor will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. Any potential conflicts of interest must receive internal, documented approval. Such documentation must be saved in accordance with applicable retention policies.

It is not permissible for the executive level staff or compliance officer of the MHP to be employed by one of their subcontractors in such a capacity.

34. Schedule A, Statement of Work Section1.1, XIX. A. Fraud, Waste and Abuse (2a.(i.)) is hereby deleted in its entirety, (2b.) and (2e.)

are hereby added in its entirety, (2a.(ii.)) is renumbered to (2b.(ii.)), (2b.-2c.) are renumbered to (2c.- 2e.), (2d.-2g.) are renumbered to (2f.-2i.), 2h.(viii.)) is hereby deleted and replaced in its entirety with the following:

a. Treatment of recoveries made by the Contractor or its subcontractors of overpayments to providers [in accordance with 42 CFR 438.608(d)(1)].

i. When the Contractor or its subcontractors recovers payments to providers:

i. The Contractor may retain the recovered overpayment including those based upon fraud, waste, or abuse.

ii. The Contractor or its subcontractors must adjust encounter data related to the recovered funds appropriately within CHAMPS within 45 days of exhausting appeal periods for identified overpayments. Reporting of recoveries will occur via monthly, quarterly, and annual submissions to MDHHS-OIG using the corresponding templates provided.

iii. In the event the Contractor receives a repayment stemming from an external investigation (state or federal), the Contractor must contact MDHHS-OIG within 30 calendar days to initiate the return of any applicable funds. Any applicable documentation will be requested at such time.

e. In the event the $5,000 threshold is not met, but there is still a heightened concern of a potential credible allegation of fraud (e.g. beneficiary harm or extenuating circumstances), the contractor must reach out to discuss the possibility of a referral with their assigned analyst as there can be exceptions that warrant referral.

2h.(viii.)) Pursuant to 42 U.S.C.1396b, the State has one year from the date of discovering an overpayment before it must refund the federal portion of the overpayment to the federal government, regardless of recovery from the Provider. Overpayments identified by the State will be recovered from the Contractor via an MDHHS withhold or offset from the next capitation payment or primary push pay to the Contractor.

35. Schedule A, Statement of Work

Section 1.1, XIX. A. Fraud, Waste and Abuse, (5a.ii. and iii.) are hereby added in their entirety, and (5a.ii. and iii.) are renumbered to (5a.iv. and v.), (5d.-5f.) are hereby deleted and replaced in their entirety as follows:

5a. ii. At a minimum, all allegations within MDHHS-OIG audit referrals to the Contractor must be investigated to either substantiate or refute any and all items within the complaint. In addition, a detailed summary of findings must be produced and include all items outlined in the audit referral. Insufficient investigations and/or summaries will be returned to the Contractor to have additional work performed until all items have been resolved.

5a. iii. Investigations related to MDHHS-OIG audit referrals must be initiated as soon as possible, but no later than 30 calendar days from the date sent by MDHHS-OIG.

5d. Data Mining Activities – Contractor must have surveillance and utilization control programs and procedures (42 CFR 456.3, 456.4, 456.23) to safeguard the Medicaid funds against unnecessary or inappropriate use of Medicaid services and against improper payments. Data mining must be performed at least annually.

Methods may include, but are not limited to, statistical models, complex algorithms, and pattern recognition programs to detect possible fraudulent or abusive practices. The Contractor must report all data mining activities performed (including all program integrity cases opened as a result) within the previous quarter to MDHHS-OIG. See Section 1.1.XIX.B of this Contract for the method and timing of such reporting.

5e. Preliminary Investigations – Contractor must promptly perform a preliminary investigation of all incidents of suspected Fraud, Waste and Abuse. The Contractor must report all program integrity cases opened within the reporting period to MDHHS-OIG. See Section 1.1.XIX.B of this Contract for the method and timing of such reporting. All confirmed or suspected provider Fraud must immediately be reported to MDHHS-OIG.

Unless prior written approval is obtained from MDHHS-OIG, Contractor must not take any of the following actions on a potential credible allegation of fraud as they specifically relate to Michigan Medicaid claims:

i. Contact the subject of the investigation about any matters related to the investigation;

ii. Enter into or attempt to negotiate any settlement or agreement regarding the incident; or

iii. Accept any monetary or other thing of valuable consideration offered by the subject of the investigation in connection with the incident.

5f. Audit Requirements – Contractor must conduct risk-based auditing and monitoring activities of provider transactions, including but not limited to, claim payments, vendor contracts, credentialing activities and Quality of Care/Quality of Service concerns that indicate potential Fraud, Waste or Abuse. These audits must include a retrospective medical and coding review on the relevant claims.

Any tips or grievances received by the Contractor must be triaged or otherwise addressed within 30 calendar days from the date of the complaint. Any resulting investigations must be initiated within 30 calendar days of the initial triage.

In accordance with the Affordable Care Act, Contractor must promptly report overpayments made by Michigan Medicaid to the Contractor as well as overpayments made by the Contractor to a provider and/or Subcontractor. See Section 1.1.XIX.B of this Contract for the method and timing of such reporting.

36. Schedule A, Statement of Work

Section 1.1, XIX. A. Fraud, Waste and Abuse (9.) is hereby deleted and replaced in its entirety with the following:

Provision for the Contractor’s suspension of payments to a Network Provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. A credible allegation of fraud may be an allegation, which has been verified by the State, from any source, including but not limited to the following:

a. Fraud hotline complaints;

b. Claims data mining; or

c. Patterns identified through provider audits, civil false claims cases and law enforcement investigations.

37. Schedule A, Statement of Work

Section 1.1, XIX. B. Reporting is hereby deleted and replaced in its entirety, (1.) is hereby added in its entirety, and (1.-7.) are hereby renumbered to (2.-8.) with the following:

Contractor must send all program integrity notifications and reports to the MDHHS-OIG sFTP. The Contractor must follow the procedures and examples contained within the MDHHS-OIG submission forms and accompanying guidance document. See Appendix 19 for the listing of notification forms and reports and their respective due dates.