240000001369.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 6 to

Contract Number MA240000001369

C O

N

TR

AC

TO

R

PRIORITY HEALTH CHOICE, INC.

1231 E Beltline, Grand Rapids MI 49525

Bethany Swartz

615-604-1290

Bethany.swartz@priorityhealth.com

CV0014435

ST

AT

E

Pr og ra m

M an ag er

Jennifer Therrien MDHHS

517-284-1145

TherrienJ1@michigan.gov

C on tr ac t Ad m in is tr at or Marissa Gove DTMB

(517) 449-8952 govem1@michigan.gov

CONTRACT SUMMARY

Comprehensive Health Care Program – DHHS (Regions 2, 3, 4, 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

$6,324,028,500.00

VALUE OF CHANGE NOTICE

$0.00

ESTIMATED AGGREGATE CONTRACT VALUE

$6,324,028,500.00

DESCRIPTION

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

Effective March 19, 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 FEBRUARY 15, 2026

1. Schedule A, Statement of Work Section 1.1, III. A. Value-Based Payment Models (1.) is hereby deleted and replaced in its entirety with the following:

Consistent with MDHHS’s policy to move reimbursement from fee-for-service (FFS) to value-based payment models, Contractor must increase the total percentage of health care services reimbursed under value-based contracts over the term of the agreement. The Contractor must ensure that a minimum of 50% of health care service reimbursement is under value-based contracts in categories 2C, 3, and 4 of the Health Care Payment Learning and Action Network (LAN) Alternative Payment Model (APM) Framework, that a minimum of 12.5% of health care service reimbursement is under value-based contracts in LAN categories 3 and 4 of the APM Framework, and that a minimum of 2.5% of health care services reimbursement is made based on a provider incentive under value-based contracts for the fiscal year 2026 reporting period.

2. Schedule A, Statement of Work Section 1.1, VI. D. Pharmacy Services (33.f.) is hereby deleted and replaced in its entirety with the following:

Disclosure of Financial Terms: Upon request, the Contractor must disclose to MDHHS all financial terms and arrangements for payment of any kind that apply between the Contractor and PBM or PBA. This disclosure must include financial terms and payment arrangements for formulary management, drug-switch programs, educational support, claims processing, pharmacy network fees, data sales fees, and all other fees. MDHHS acknowledges that such information may be considered confidential and proprietary and thus must be held strictly confidential by MDHHS as specified in the Standard Contract Terms, Section 35 – Non-Disclosure of Confidential Information of this Contract.

3. Schedule A, Statement of Work Section 1.1, VIII. C. Collaboration with Certified Community Behavioral Health Clinics (CCBHC) is hereby added in its entirety with the following, and C. is hereby renumbered to D:

Collaboration with Certified Community Behavioral Health Clinics (CCBHC)

1. For Enrollees who have significant mental health issues and complex physical comorbidities, as identified in Sections VIII.B.5.a.

and VIII B.5.b., and who have received a service from a CCBHC provider, Contractor must:

a. Work collaboratively with the CCBHC to regularly identify and coordinate the provision of services to shared Enrollees;

b. Work with CCBHC to provide care management services, including joint care planning that are based on Enrollee needs and goals, as defined by the Enrollee, and, for child and adolescent Enrollees, their caregiver(s);

c. Meaningfully utilize the MDHHS-supported web-based care management system, CareConnect360 (CC360) to document a jointly created care plan and to track contacts, issues, and services regarding shared Enrollees.

4. Schedule A, Statement of Work Section 1.1, XI. I. Utilization Management (5.e.) is hereby deleted and replaced in its entirety with the following:

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 February 15 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;

5. Schedule A, Statement of Work Section 1.1, XVIII. C. Accreditation/Certification Requirements (3.) and (3.a.) are hereby deleted and replaced in its entirety with the following:

Contractor must hold and maintain NCQA Health Outcomes or Community-Focused Care Accreditation in the State of Michigan. Any Contractor not currently accredited in the State of Michigan prior to 10/1/2024 must obtain accreditation within two years of contract start date or upon a separately agreed on timeframe at the sole discretion of MDHHS (see Section 1.1.XX.A.3.m). Contractor must also provide the State information regarding the Contractor’s progress in achieving Health Outcomes or Community- Focused Care Accreditation upon the State’s request.

a. The Contractor must provide the State with evidence of the Contractor’s Health Outcomes or Community-Focused Care Accreditation, including the results of the Contractor’s most recent NCQA review. The Contractor shall authorize NCQA to provide the State a copy of the most recent Health Outcomes or Community-Focused Care Accreditation review for the Contractor.

6. Schedule A, Statement of Work Section 1.1, XVIII. F. Physician Incentive Plan (1.) is hereby deleted and replaced in its entirety with the following:

Contractor must disclose to MDHHS, upon request, the information on their Provider incentive plans listed in 42 CFR 422.208 and 422.210, as required in 42 CFR 438.3(i).

7. Schedule A, Statement of Work Section 1.1, XX. A. Contract Remedies and Sanctions (3.m.) is hereby deleted and replaced in its entirety with the following:

NCQA Health Outcomes or Community-Focused Care Accreditation

8. Schedule A, Statement of Work Section 2.1, I. C. Administrative Personnel Responsibilities (4.d.) is hereby deleted in its entirety.

9. Schedule A, Statement of Work Section 2.3, III. A. Related Party Agreements (1.b.) is hereby deleted and replaced in its entirety with the following:

Contractor must notify and provide executed related party agreements in their entirety to MDHHS upon request. MDHHS acknowledges that such information may be considered confidential and proprietary and thus must be held strictly confidential by MDHHS as specified in the Standard Contract Terms, Section 35 – Non-Disclosure of Confidential Information of this Contract.

10. Schedule A, Statement of Work

Section 4.1, IV. A. Performance Bonus (Quality Withhold) is hereby deleted and replaced in its entirety with the following:

Performance Bonus (Quality Withhold) In accordance with MDHHS’ commitment to quality improvement, innovation, and operational excellence, MDHHS will withhold a percentage of the capitation payment from Contractor and make the return of these withheld funds contingent upon Contractor meeting certain quality and performance metrics.

For fiscal year 2026, MDHHS will withhold 2.00% of the capitation payment.

MDHHS reserves the right to revise the withhold percentage ahead of each fiscal period. Withheld funds will be used for the Contractor performance bonus awards, specified in Appendix 5, and support program initiatives as part of the MDHHS quality strategy. Awards will be made to Contractor according to criteria established by MDHHS (see Appendix 5) and in compliance with 42 CFR 438.6(b). Contractor’s performance will be measured during the rating period in which the withhold arrangement is applied.

11. Schedule A, Statement of Work Definitions, Certified Community Behavioral Health Clinics (CCBHC) is hereby added in its entirety with the following:

12. Schedule A, Statement of Work

Appendix 3 Title and Health Plan Abortion Report are hereby deleted and replaced in its entirety, and Prior Authorizations are hereby added in its entirety with the following:

APPENDIX 3: FY 2026 REPORTING REQUIREMENTS FOR MEDICAID HEALTH

PLANS

These reports must be submitted in addition to contract compliance review submission requirements. All reports must be shared electronically via the MDHHS File Transfer Application, unless otherwise noted.

Exceptions are the Medicaid health equity data, encounter data, provider file, and PCP Submission file which are submitted electronically via the FTS. Barrier Report is submitted via email.

Report Reference

Due Date Period Covered Instructions/Format

Annual Submissions Health Plan Abortion

10/5/2026 10/1/2025 – 9/30/2026 MSA-0128 accompanied with all MSA-4240s

Certified Community Behavioral Health Clinics (CCBHC)

CCBHCs provide outpatient behavioral health services to anyone with a behavioral health diagnosis regardless of insurance type, geographic location, or ability to pay. CCBHCs must provide a comprehensive array of services including mental health and substance use treatment, 24/7 crisis services, medication assisted treatment, and care coordination across service providers.

Report Quarterly Submissions (Previous months reporting) Prior Authorizations

March 31 June 30 September 30 December 31

July 1 – September 30 October 1 – December 31 January 1 – March 31 April 1 – June 30

MDHHS Template

13. Schedule A, Statement of Work

Appendix 4 Introduction, MDHHS Dental Measures (Restorative Dental Visits in Pregnancy, Emergency dental follow-up in all adults in the Adult Dental program), CMS Core Set and Managed Care Quality Measures (title), Maternal Health Measures (Prenatal Immunization Status, Pregnancy Management) are hereby deleted and replaced in their entirety with the following:

APPENDIX 4: PERFORMANCE MONITORING STANDARDS

MEDICAID MANAGED CARE

Medicaid Health Plans

(Effective October 1, 2025 – September 30, 2026)

PERFORMANCE MONITORING STANDARDS

PURPOSE: The purpose of the performance monitoring standards is to establish an explicit process for the ongoing monitoring of health plan performance in important areas of quality, access, and reporting. Through this appendix, the performance monitoring standards are incorporated into the Contract between the State of Michigan and Medicaid Health Plans.

The process is dynamic and reflects state and national issues that may change on a year-to-year basis. Performance is shared with Medicaid Health Plans and compares performance of each plan over time, to other health plans, and to industry standards, where available.

The Performance Monitoring Standards address the following:

• MDHHS Dental Measures

• CMS Core Set Measures and Managed Care Quality Measures

• Maternal Health Measures

• Chronic Conditions Measures

For each performance area, the following categories are identified: Measure, Goal, Minimum Standard for each measure, Data Source, and Monitoring Intervals (annually, quarterly, monthly).

Minimum performance monitoring standards for FY 2026 are included in this document. Failure to meet the minimum performance monitoring standards may result in the implementation of remedial actions and/or improvement plans as outlined in the contract.

MDHHS Dental Measures, some Maternal Health Measures, and some Chronic

Conditions Measures are run with custom coded queries.

CMS CORE SET and MANAGED CARE QUALITY MEASURES

Prenatal Immunization Status

Pregnant members who received influenza and tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccinations during the measurement period.

≥20%

MDHHS

Data Warehouse

Quarterly

Restorative Dental Visits in Pregnancy

All pregnant members who are enrolled in the adult dental benefit under the Medicaid health plan and who received at least one restorative dental service during their pregnancy or 90 days postpartum.

Informational Only

MDHHS Data Warehouse Quarterly

Emergency dental follow-up in all adults in the Adult Dental program

All members who are enrolled in the adult dental benefit under the MHP who visited the emergency department for non-traumatic dental condition and who received a routine dental visit with a dentist in a dental office for a comprehensive or periodic oral diagnostic visit within 90 days of the emergency visit for dental.

≥50% MDHHS Data Warehouse

Quarterly

Pregnancy Management

Pregnant members who received the following services:

• HIV testing

• Chlamydia screening (members less than 25 years of age)

• Syphilis screening.

• HBsAg testing

• Group B

Streptococcus testing.

• Gonorrhea screening (members less than 25 years of age)

• HIV testing in the 1st or 2nd trimester AND another HIV test in the first or second month of the 3rd trimester

• HBsAg testing in the 1st or 2nd trimester AND another HBsAg test in the first or second month of the 3rd trimester

• Syphilis screening in the 1st or 2 and trimester AND another syphilis screening in the first or second month of the 3rd trimester

No contractually required minimum; refer to Appendix 5C for withhold benchmarks

MDHHS

Data

Warehouse Quarterly

14. Schedule A, Statement of Work

Appendix 5 (Quality Withhold Distribution) is hereby deleted and replaced in its entirety with the following:

QUALITY WITHHOLD DISTRIBUTION

APPENDIX FY2026 WITHHOLD

DISTRIBUTION

PERCENTAGE

FY2027 PROJECTED

WITHHOLD

DISTRIBUTION

PERCENTAGE

5A Performance Bonus Template

35% 40%

5B Encounter Quality Initiative (EQI)

7% 8%

5C Population Health Management

17% 21%

5D Dental Quality 18% 18%

5E Integration of Behavioral Health and Physical Health Services (Joint Metrics)

10% N/A

5F Alternative Payment Model (APM)

13% 13%

Total: 100% 100%

15. Schedule A, Statement of Work

Appendix 5C, HIV Viral Load Suppression Measure (HVL-AD- health equity scoring), Comprehensive HIV/STI Plan, Outreach and Engagement to Facilitate Entry to Primary Care (Chart) are hereby deleted and replaced in their entirety with the following:

HIV Viral Load Suppression

(HVL-AD) –

health equity scoring

Improve the disparity between the reference population and at least one comparison population (if necessary, comparison populations will be combined to achieve a sufficient denominator)*.

Comparison of CY2024 and CY2025

Comprehensive HIV/STI Plan:

In FY26, plans will create a comprehensive HIV/STI plan for all persons 21 and older, using MDHHS provided reporting template.

Activities: MDHHS will send a template for plans to complete. There will be a pre- and final submission in this activity.

• Pre-submission due date: July 17, 2026, before 5:00 pm EST

• Final submission due date: September 18, 2026, before 5:00 pm EST

Scoring rubric: MDHHS will award a possible 5 points for satisfactory completion of the pre- and final submissions.

Measure Benchmark Points Possible

Performance Period

Outreach and Engagement to Facilitate Entry to Primary Care

(ENT-PC)

40% 2 CY2025

16. Schedule A, Statement of Work

Appendix 5D Diagnostic Dental Services, Preventive Dental Services, Diabetic Preventive Dental Visit, and Ambulatory Care Sensitive Emergency Department Visits for Non-Traumatic Dental Conditions in Adults are hereby deleted and replaced in their entirety with the following:

Diagnostic Dental Services*

All members who are enrolled in the adult dental benefit under the MHP and who received at least one diagnostic dental service within the measurement period.

≥35% = 2 points ≥40% = 5 points

Statistically Significant

Improvement = 1 point

FY26

(October 2025 -

September 2026)

Preventive Dental Services*

All members who are enrolled in the adult dental benefit under the MHP and who received at least one preventive dental service within the measurement period.

≥20% = 2 points ≥30% = 5 points

Statistically Significant

Improvement = 1 point

FY26

(October 2025 -

September 2026)

Diabetic Preventive Dental Visit *

All members who are enrolled in the adult dental benefit under the MHP with Type 1 or Type 2 diabetes, and who received at least one preventive dental service within the measurement period.

≥20% = 3 points ≥30% = 5 points

Statistically Significant

Improvement = 1 point

FY26

(October 2025 -

September 2026)

Ambulatory Care Sensitive Emergency Department Visits for Non- Traumatic

Rate of emergency dental care utilization per 100,000 adult members

Rate1: Less than 3,000 visits per

100,000 beneficiaries ages 21-34 = 2.5 points

FY26

(October

2025- September

2026)

Conditions in Adults (EDV-

AD)*

Rate 2: Less than 2,000 visits per 100,000 adult beneficiaries ages 35-64 = 2.5 points

Statistically Significant

Improvement = 1 point for each Rate 1 and/or

Rate 2, if benchmark was not met.

(Reverse Measure)

Recommended Dental Plan — Adult CAHPS Reporting

Rate of CAHPS survey respondents who indicated they would recommend their dental plan.

≥87% 5

FY25

CAHPS

survey

Published in

Access to Dental Care — Adult CAHPS Reporting

Rate of CAHPS survey respondents who indicated they had access to dental care.

≥70%

FY25

CAHPS

survey

Published in

17. Schedule A, Statement of Work

Appendix 5D, Title and Initiation and Engagement of Substance Use Disorder Treatment (IET) are hereby deleted and replaced in their entirety with the following:

APPENDIX 5E- Integration of Behavioral Health and Physical Health Services

INTEGRATION OF BEHAVIORAL HEALTH AND PHYSICAL HEALTH SERVICES

Initiation and Engagement of Substance Use Disorder Treatment

(IET)

(20 points)

Members who had new substance use disorder (SUD) episodes that result in treatment initiation and engagement.

The Contractor will be measured against an initiation (IET 14) minimum standard of 42% (5 points) and an engagement (IET 34) minimum standard of 15% (5 points). The measurement period will be calendar year 2025.

Data will be stratified by race/ethnicity and provided to plans. The Contractor will be incentivized to improve the disparity between the reference population and at least one comparison population (if necessary, comparison populations will be combined to achieve a sufficient denominator). Measurement period for improving disparities will be a comparison of calendar year 2024 with calendar year 2025. Improving disparities for initiation (IET 14) is worth 5 points and improving disparities for engagement (IET 34) is worth 5 points.

The points for overall standard (item 1 above) will be awarded based on MHP/PIHP combination performance measure rates. The points for improving disparities (item 2 above) will be awarded based on individual MHP or PIHP performance over time. The total potential points will be the same regardless of the number of MHP/PIHP combinations for a given entity or number of comparison populations.

18. Schedule A, Statement of Work

Appendix 5F, APM Data Collection Tool and Dental are hereby deleted and replaced in their entirety with the following:

APM Data Collection

Tool

Submit CY25 APM Data Collection Tool.

Full points will be rewarded based on meeting MDHHS benchmarks (50% Big Numerator; 12.5% in Category 3 & 4;

2.5% in Small Numerator). Partial credit will be given for increasing APM use.

Performance measures for APM arrangements with primary care providers, including Patient Centered Medical Homes (PCMHs), must be

Scoring note:

one point deducted for every 1% under Big Numerator threshold; and one point deducted for every 0.5% under Small Numerator

Pre: April

Final: May selected from the following HEDIS quality measures as appropriate for provider type. Contractors must incentivize at least six (6) of the following performance measures:

• Adult Access to Preventive/Ambulatory Health Services

• Asthma Medication Ratio

• Breast Cancer Screening

• Cervical Cancer Screening

• Child & Adolescent Well Care

Visits (W30 and WCV)

• Childhood Immunization Status

• Chlamydia Screening

• Controlling High Blood Pressure

• Eye Exam for Patients with

Diabetes

• Kidney Health Evaluation for

Patients with Diabetes

• Lead Screening in Children Contractors may choose to include up to two (2) additional plan-driven measures that are not included in the list above.

Data Validation Review:

• Please describe in detail how payments have been categorized into APM categories.

• Please describe the steps the MHP goes through to validate the data is correct.

• Please describe any differences in approach in APM reporting and data validation in CY25 from previous years.

threshold.

Contractor must have at least one APM arrangement with a dental provider in place by the end of FY26. Contractor must provide evidence that arrangement is in place.

10 September

19. Schedule A, Statement of Work

Appendix 12, (7) Community Engagement is hereby deleted and replaced in its entirety with the following:

7. Community Engagement

The Contractor must engage community partners or coalitions in each of the Regions they are contracted to serve on how to invest their Community Reinvestment Obligation.

In Regions where they exist, the Contractor must fulfill this requirement by engaging the Michigan Department of Health and Human Services designated Michigan Hub sites. In Regions with multiple Michigan Hub sites, the Contractor must engage with all Michigan Hub sites in a Region that are willing and have capacity to engage with the Contractor.

In Regions that do not have Michigan Hub sites, the Contractor must fulfill this requirement by engaging community partners or coalitions that:

• Represent multiple sectors;

• Include individuals who live in the community; and

• Focus on priorities identified by the community.

The Contractor must engage with external community coalitions, when available, rather than developing a separate entity to meet this requirement or using a Contractor-specific committee. If Michigan Hub sites are unavailable in a Region or do not have capacity to engage with the Contractor to fulfill this requirement, appropriate coalitions could include, but are not limited to, Community Health Innovation Regions and Regional Health Equity Councils.

The Contractor must engage with its community partners or coalitions at least three times each year throughout the development of the Community Reinvestment Spending Plan and publication of the Community Reinvestment Expenditures Report, including but not limited to:

• Prior to the development of the Community Reinvestment Spending Plan, so community partners can provide input on potential CBOs and activities to fund.

• Once the Community Reinvestment Spending Plan has been drafted but prior to submission to MDHHS, so community partners can provide input on the draft Plan.

• Once the Community Reinvestment Expenditures Report has been drafted, so the community knows how the funds were invested.

Community engagement must be documented in the appropriate section of the Plan.

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 MA240000001369

C O

N

TR

A C

TO

R

PRIORITY HEALTH CHOICE, INC.

1231 E Beltline, Grand Rapids MI 49525

Bethany Swartz

615-604-1290

Bethany.swartz@priorityhealth.com

CV0014435

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 2, 3, 4, 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

$6,324,028,500.00

VALUE OF CHANGE NOTICE

$0.00

ESTIMATED AGGREGATE CONTRACT VALUE

$6,324,028,500.00

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

Appendix 23 Capitation Rate Certification is hereby deleted and replaced in its

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 2, 3, 4, 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

1231 E Beltline, Grand Rapids MI 49525

Bethany Swartz

615-604-1290

Bethany.swartz@priorityhealth.com

CV0014435

PRIORITY HEALTH CHOICE, INC.

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 MA240000001369 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

$6,324,028,500.00 $0.00 $6,324,028,500.00

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

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…