250000000215.pdf

STATE OF MICHIGAN

ENTERPRISE PROCUREMENT

DTMB

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

CONTRACT CHANGE NOTICE

CONTRACT SUMMARY

Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs)

INITIAL EFFECTIVE DATE INITIAL EXPIRATION DATE INITIAL AVAILABLE OPTIONS EXPIRATION DATE

BEFORE

January 1, 2025 December 31, 2033 3 - 1 Year December 31, 2033

PAYMENT TERMS DELIVERY TIMEFRAME

ALTERNATE PAYMENT OPTIONS EXTENDED PURCHASING

MINIMUM DELIVERY REQUIREMENTS

N/A

P-Card Direct Voucher (PRC) Other Yes No

1231 East Beltline Northeast

Grand Rapids, MI 49525

Scott Norman

248-880-3191 scott.norman@priorityhealth.com

CV0014435

Priority Health Choice, Inc.

C O

N

TR

A C

TO

R

517-643-3746

SeagerM@michigan.gov

Marissa Gove

(517) 449-8952

DTMB

Matthew Seager MDHHS govem1@michigan.gov

C ontract

A dm inistrator Program M anagerSTA

TE

N/ANET 45

Change Notice Number 1

Contract Number MA250000000215 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

$0.00 $0.00 $0.00

DESCRIPTION

Effective August 12, 2025, this Contract is amended in accordance with the attached revisions and the Contractor's Representative is changed to Heather DeHaan. All other terms, conditions, specifications and pricing remain the same. Per contractor and agency agreement, and DTMB Central Procurement approval.

Change Notice 1 - Changes

1. Statement of Work, Background is revised.

In May 2022, CMS finalized a requirement for states participating in the Financial Alignment Initiative capitated model demonstration to end their programs by 12/31/2025 or transition them into integrated Dual Eligible Special Needs Plans (D-SNP).

Michigan submitted a letter of intent to CMS to transition MI Health Link (MHL) to an integrated D- SNP by January 1, 2026.

To align with the new CMS rules, MDHHS will transition the MHL Program to a Highly Integrated Dual Eligible Special Needs Plan (HIDE SNP).

a. A HIDE-SNP is a specific type of Medicare Advantage plan that is designed to meet the needs of those dually eligible for Medicare and Medicaid.

b. The HIDE-SNP will integrate long-term service and supports (LTSS) and contracted managed care plans will provide all Medicare and most Medicaid covered benefits for their dual-eligible enrollees through capitated, D-SNP only contracts, but specialty Medicaid behavioral health services will remain carved out and will continue to be provided by Regional Pre-Paid Inpatient Health Plans (PIHPs).

MDHHS remains committed to ensuring the improved care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees through a HIDE-SNP; with the expectation of providing the greatest degree of continuity in the program benefits and expectations for beneficiaries, providers, and health plans.

The Integrated Care Transition Pillars include:

1. Foster Integration and Continuity – The goal of the HIDE-SNP program is to continue to improve quality and access to care by aligning Medicare and Medicaid and bridging the divide between the physical health, long term care, and behavioral health systems.

Enrollee’s providers and amount, scope and duration of services at the time of enrollment must be continued until the enrollee can be assessed.

2. Reduce Racial Disparities – MDHHS will use a data driven approach to identify root causes of racial and ethnic disparities and address health inequity at its source. MDHHS will work to reduce causes of inequitable access to programs and services that impact social determinants of health. Input will be gathered from stakeholders at all levels to ensure services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds. The HIDE-SNP program will incorporate processes to align program operations and strategies related to quality of care and services, data driven outcomes measurement, and address social determinants of health, health equity and disparities. MDHHS will improve service delivery to ensure that all eligible individuals receiving services have equitable access to services and resources in order to improve health outcomes and reduce racial disparities.

3. Improve Care Delivery – Care delivery in the HIDE-SNP program will be based on a person-centered approach that emphasizes the whole person and care coordination to comprehensively address enrollees’ needs.

4. Promote Self Determination – MDHHS values and will require pathways that provide enrollees with meaningful authority to control and direct long-term supports and services in the HIDE-SNP program. True self-determination requires a shift from the approaches that fit enrollees into an existing service array to approaches that are truly enrollee-centered and enrollee-controlled. Arrangements that support self-determination ensure methods for enrollees to exert direct control over how, by whom, and to what ends they are served and supported.

5. Build a Culture of Quality - The HIDE-SNP program will incorporate principles of continuous quality improvement into all aspects of its operations. Using an integrated data-driven approach to monitoring, prioritizing, and identifying quality improvement opportunities, it will aim to improve outcomes and ensure timely access to high-quality services for dually eligible Enrollees. Through policy development and targeted interventions, it will advance MDHHS' strategic quality objectives of providing high quality care and high levels of access to care, strengthening person and family-centered approaches to care, promoting effective care coordination and communication of care among managed care programs, providers, and stakeholders, reducing racial and ethnic disparities in healthcare and health outcomes, and improving quality outcomes and disparity reduction through value-based initiatives and payment reform.

2. Statement of Work, Scope is revised.

MDHHS seeks to increase integration of care and improve health outcomes through increased alignment of Medicaid and Medicare. The purpose of this Contract is to establish a program offering direct contracts with Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs). HIDE SNPs will provide aligned coverage of most Medicaid benefits, excluding certain behavioral health services, but including long-term services and supports, under a capitated contract that meets the requirements set forth in 42 CFR 422.107. The HIDE SNP program will be fully operational commencing January 1, 2026, in limited regions of the State of Michigan (“State”). On January 1, 2027, the program will be extended to the entire State.

A. Applicable Laws, Regulations, and Interpretations list

a. Contractor has entered into a contract with the Centers for Medicare & Medicaid

Services (“CMS”) to provide a HIDE SNP (“MA Agreement”).

b. Under the Medicare Improvement for Patients and Providers Act of 2008 (“MIPPA”) and resulting regulations, CMS requires Contractor to also enter into an agreement with the State to provide or arrange for benefits to be provided, for which a dually eligible individual is entitled to receive.

c. Under the Bipartisan Budget Act of 2018 and resulting regulations, CMS requires Contractor to maintain a level of integration as determined by the State.

d. MI is pursuing D-SNP only contracts pursuant through 42 CFR 422.107(e), and as such, requires MA organizations offering HIDE SNPs in Michigan to do the following:

i. Apply for, and seek CMS approval to establish and maintain, a contract that only includes one or more dual eligible special needs plans with a service area limited to the State.

ii. Use required materials that integrate Medicare and Medicaid content, including at a minimum the Summary of Benefits, Formulary, and combined Provider and Pharmacy Directory that meets Medicare and Medicaid managed care requirements consistent with applicable regulations in parts 422, 423, and 438 of 42 CFR Subchapter B.

This is a Contract to obtain the services to provide Medicare and Medicaid services for dually eligible beneficiaries in the service areas within the State of Michigan, as described herein. This is a unit price-per member per month (PMPM) Capitated Rate Contract. Dually eligible beneficiaries must have a choice among Contractors. Therefore, the State cannot guarantee a specific number of Enrollees to Contractor. The Contractor must employ a population health management approach in all programs and interventions delivered to dually eligible beneficiaries.

Phased Implementation: This contract will be implemented in two phases as follows:

On January 1, 2026, the Contract will be implemented in Region 1, Region 8, Region 10, and Region

12. For definitions of regions and counties included in each region see Section 3 below and Appendix B.

On January 1, 2027, the Contract will be implemented in all other regions in the State.

3. Section 1.1 General Requirements, B. is revised and G. is added.

B. Contractor must comply with all provisions of The Medicaid Providers Manual (found at https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf) and Medicaid Policy which may be revised as needed (found at https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines) applicable to Contractors unless provisions of this Contract stipulate otherwise.

G. Contractor must comply with all applicable provisions of federal and State laws, policies, regulations, guidance, waivers and standards, and Demonstration terms and conditions, including the implementation of a compliance plan. The Contractor must comply with the Medicare Advantage requirements in Part C of Title XVIII, and 42 C.F.R. Part 422 and Part 423.

4. Section 1.2 Service Area, B. and C. are revised.

https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/practiceguidelines

B. Michigan Regions

a. Contractor must operate in one or more of 12 Regions throughout the State for the provision of Covered Services.

b. Contractor must provide services in accordance with this Contract to beneficiaries residing in all Counties within the Region(s) it is approved to cover.

c. Contractor must provide evidence of Medicaid network adequacy to MDHHS annually and as required in this Contract. Regions are defined and numbered as follows:

i. Region 1: Alger, Baraga, Chippewa, Delta, Dickinson, Gogebic, Houghton, Iron, Keweenaw, Luce, Mackinac, Marquette, Menominee, Ontonagon, Schoolcraft

ii. Region2: Antrim, Benzie, Charlevoix, Emmet, Grand Traverse, Kalkaska, Leelanau, Manistee, Missaukee, Wexford

iii. Region 3: Alcona, Alpena, Cheboygan, Crawford, Iosco, Montmorency, Ogemaw, Oscoda, Otsego, Presque Isle, Roscommon

iv. Region 4: Allegan, Ionia, Kent, Lake, Mason, Mecosta, Muskegon, Montcalm, Newaygo, Oceana, Osceola, Ottawa

v. Region 5: Arenac, Bay, Clare, Gladwin, Gratiot, Isabella, Midland, Saginaw

vi. Region 6: Genesee, Huron, Lapeer, Sanilac, Shiawassee, St. Clair, Tuscola

vii. Region 7: Clinton, Eaton, Ingham

viii. Region 8: Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, Van Buren

ix. Region 9: Hillsdale, Jackson, Lenawee, Livingston, Monroe, Washtenaw

x. Region 10: Macomb

xi. Region 11: Oakland

xii. Region 12: Wayne

d. Contractor must only enroll eligible beneficiaries residing within the counties in its service area.

C. Service Area Expansion Expansion of, or changes to, Contractor’s Service Area will be at the sole discretion of MDHHS with approval from CMS.

5. Section 2.4 Contractor Enrollment, C. a. and b. are added.

C. Contractor must accept enrollment for all Potential Enrollees, as described in this section at any time without regard to physical or mental condition, age, gender, sexual orientation, religion, creed, race, color, physical or mental disability, national origin, ancestry, pre-existing conditions, expected health status, or need for health care services.

a. Involuntary disenrollment requests due to disruptive behavior in accordance with 42 CFR §§ 422.74(d)(2), 422.74(e)(1) must be submitted to the Contractor’s Medicare Account Manager for review and approval.

b. Involuntary disenrollment requests in accordance with 42 CFR 438.56 are limited to substantiated allegations of Medicaid fraud committed by the enrollee and must be submitted to the Contractor’s MDHHS Contract Manager for review and approval.

6. Section 2.5 Methods of Enrollment, A. a. is revised.

a. If Contractor uses Agents and Brokers or makes payments to third party marketing organizations to sell its HIDE SNP plan, Contractor must adhere to all applicable Michigan laws and regulations related to the licensure and activities of Agents and Brokers and follow all requirements set forth in 42 CFR 422.2274 and 423.2274 as applicable.

7. Section 2.6 Deemed Enrollment, A. is revised.

A. Contractor must offer Enrollees who lose Medicaid eligibility no less than a three-month deeming period of continued enrollment in the HIDE SNP to minimize risks and maximize continuity of care during periods of temporary Medicaid eligibility loss, in accordance with § 422.52(d). During any period of continued enrollment, Contractor will provide all Medicaid services called for under this Contract.

8. Section 3.1 HIDE SNP Requirements, A. and A. b. are revised.

A. For purposes of this Contract, Highly integrated dual eligible special needs plan means a dual eligible special needs plan as defined by 42 CFR §422.2 offered by an MA organization that provides coverage of Medicaid benefits, including primary and acute care, under a capitated contract that meets the following requirements:

b. This Contract requires the coverage of the following benefits to the extent Medicaid coverage of such benefits is available to individuals eligible to enroll in a HIDE SNP in the State except as approved by CMS under 42 CFR § 422.107(g) or (h) (See Appendix M):

i. Long-term services and supports, including community-based long-term services and supports and some days of coverage of nursing facility services during the plan year; or

ii. Behavioral health services covered by Medicaid but not provided by Prepaid Insurance Health Plans; and

9. Section 3.2 Medicare and Medicaid Coverage, A. b. is revised and E is added.

b. Contractor is required to provide at least one mandatory supplemental benefit that complements the LTSS covered under this Contract.

E. When the Contractor receives a request for information from the HIDE-SNP ombudsman program related to a covered service or complaint related to a covered service, the Contractor must respond timely to that request and any additional follow-up requests.

10. Section 3.3 Medicaid Covered Services Not Covered by Medicare, I, J, and K are revised.

I. Contractor must ensure all reporting requirements, quality assurance, and compliance activities required by MDHHS of Contractor apply equally to all Subcontractors used for the provision of Covered Services.

a. Contractor must ensure that there is a written agreement that specifies the activities and report responsibilities delegated to the Subcontractor and provides for revoking delegation (whether by Contractor, MDHHS or CMS) or imposing monetary Sanctions and/or other Sanctions if the Subcontractor’s performance is inadequate.

b. If deficiencies or areas for Improvement are identified, Contractor and the Subcontractor will take corrective action.

J. Contractor must comply with provisions of MCL 400.109(h) as it relates to pharmaceuticals covered under Michigan Medicaid benefit.

K. Unless otherwise specified in this Contract, Contractor must abide by MDHHS’ telehealth coverage and reimbursement policies for Medicaid-covered services. (See Final-Bulletin- MMP-23-10-Telemedicine.pdf).

11. Section 3.5 Home and Community-Based Waiver Services, C. is revised.

C. As set forth in Section 36.7, Contractor will ensure that the Michigan Medicaid Nursing Facility Level of Care Determination (LOCD) is conducted, as necessary, to determine eligibility for HCBS waiver services.

12. Section 3.7 Nursing Facility Care, A. is revised.

A. Contractor must provide long term custodial care, skilled nursing or rehabilitation services in a facility licensed in accordance with MCL 333.1101 – 333.25211 and certified in accordance with 42 C.F.R.§ 483 designed to meet an Enrollee’s needs. Medicaid custodial care is not limited and may exceed 180 days.

13. Section 3.8 Nursing Facility Payment is revised.

A. For traditional Medicaid nursing facility days of care, Contractor must negotiate with Nursing Facilities to establish rates.

B. It is the responsibility of the Nursing Facility provider to collect the PPA from Enrollees for traditional Medicaid nursing facility days of care, and the Contractor must reduce reimbursements to Nursing Facility providers equal to the PPA amount each month.

C. The Quality Assurance Supplement (QAS) for traditional Medicaid nursing facility days of care will be paid through a directed payment as approved by CMS through the 42 C.F.R. § 438.6(c) preprint process.

D. Contractor must reimburse nursing facility providers Medicaid co-insurance for days 21 through 100 of a skilled care or rehabilitation day in accordance with the MI Coordinated Health chapter of the Medicaid Provider Manual.

E. Contractor must, as part of their skilled nursing facility benefit, provide skilled nursing level of care in a long-term care facility without a preceding acute care inpatient stay for Enrollees, when the provision of this level of care is clinically appropriate and can avert the need for an inpatient stay.

F. Pre-Eligibility Medical Expense (PEME) – A beneficiary’s eligibility for deduction of PEME from patient pay amounts does not increase Contractor’s nursing facility reimbursement rate.

14. Section 3.9 Dental Provider Payment Rules is revised.

A. The Contractor is required to pay Medicaid participating dental providers, at a minimum, the Medicaid FFS rate for covered Current Dental Terminology (CDT) codes. Medicare covered services will be paid according to Medicare policy.

15. Section 3.10 Direct Care Worker (DCW) Rates is revised.

A. In accordance with MDHHS Numbered Letter 24-59, Contractor must pay direct care workers providing services as set forth in that letter at the rate and manner according to its terms as it may be amended or replaced from time to time.

16. Section 3.13 Behavioral Health Benefit, A. is revised.

A. Contractor must provide all Medicaid behavioral health services not provided by the PIHPs, consistent with Appendix D and MDHHS Medicaid Policy.

17. Section 3.17 Pharmacy Services, A. d is hereby removed and A. e is revised.

e. Contractor must have a process to approve physicians' requests to prescribe any medically appropriate drug, vitamin or supplement that is covered on the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members, found at https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fmi.primetherapeutic s.com%2Fprovider%2Fexternal%2Fmedicaid%2Fmi%2Fdoc%2Fen-us%2FMIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx&wdOrigin=BROWSELINK.

18. Section 3.17 Pharmacy Services, D, E, F are revised.

D. Outpatient pharmacy point-of-sale coding must be updated within thirty (30) Days following MDHHS approval of a change to the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members. Point-of-sale coding must be updated within seventy-two (72) hours if an emergency change has been requested by MDHHS.

E. Contractor must provide MDHHS access to Contractor’s published formulary to facilitate Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members compliance monitoring.

F. Contractor must cover products listed on the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members in accordance with FFS coverage parameters and utilization requirements, including but not limited to:

a. Prior authorization

b. Prior authorization criteria

c. Quantity limits

d. Age

e. Gender

G. Contractor must cover all drugs found on the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members, found at https://mi.primetherapeutics.com/provider/external/medicaid/mi/doc/en-us/MIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx.

https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fmi.primetherapeutics.com%2Fprovider%2Fexternal%2Fmedicaid%2Fmi%2Fdoc%2Fen-us%2FMIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx&wdOrigin=BROWSELINK https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fmi.primetherapeutics.com%2Fprovider%2Fexternal%2Fmedicaid%2Fmi%2Fdoc%2Fen-us%2FMIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx&wdOrigin=BROWSELINK https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fmi.primetherapeutics.com%2Fprovider%2Fexternal%2Fmedicaid%2Fmi%2Fdoc%2Fen-us%2FMIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx&wdOrigin=BROWSELINK https://mi.primetherapeutics.com/provider/external/medicaid/mi/doc/en-us/MIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx https://mi.primetherapeutics.com/provider/external/medicaid/mi/doc/en-us/MIRx_medicarepartd_dual_eligible_covered_ndcs.xlsx

This list is updated monthly and Contractor must update its formulary to account for changes not less than quarterly.

19. Section 3.17 Pharmacy Services, H, I, J, K, N, O.h, O.m, O.p, O.q are hereby removed.

20. Section 3.17 Pharmacy Services, L, M, O.i are revised.

L. Contractor, including Contractor’s Pharmacy Benefit Manager (PBM) or its Subcontractors, is prohibited from negotiating any rebates with drug manufacturers for all drugs and non-drug items for which MDHHS has entered into a State supplemental rebate agreement with the manufacturer. If Contractor, its PBM or other subcontractors have an existing rebate agreement with a manufacturer, all covered outpatient drug and non-drug item claims for Medicaid participants for which MDHHS is obtaining State supplemental rebate must be exempt from such rebate agreements. This applies to both prescription, over-the-counter drugs, and non-drug items such as blood- glucose test strips. The MDHHS Medicaid Provider Manual’s Directory Appendix identifies the CMS website listing of drug manufacturers participating in the Medicaid Drug Rebate Program (MDRP). Contractor or its Subcontractors may only negotiate with and accept rebates from in relation to drugs that are not on any supplemental rebate agreement list provided by MDHHS.

M. As directed by MDHHS, Contractor must provide all pharmacy records for prior authorization to facilitate Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members compliance monitoring.

O. i. Coverage and Utilization Management tools (e.g., prior authorization, step therapy, quantity limits, and age or gender edits) may be less restrictive, but not more restrictive than the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members.

O. j. Contractor must follow the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members procedures for transitions of care and grandfathering.

O. l. Contractor must provide MDHHS with information regarding the Michigan Medicaid Part D Excluded Products Covered for Dual Eligible Members pursuant to Section 1806 of Public Act 207 of 2018.3.

O. t. Contractor must have a single Bank Identification Number (BIN))/American National Standards Institute (ANSI) Issue Identifier Number (IIN) and Processor Control Number (PCN)). The BIN/IIN and PCN are listed on the PBM/processor/plan’s Payer Sheets for trading partners to know the proper identifiers for routing transactions. Contractor must require that only these billing identifiers be used for claim submission and routing purposes for the MICH Program.

21. Section 3.19 Communicable Disease Services is hereby removed.

22. Section 3.25 Out-of-Network Reimbursement Rules, D is revised.

D. Contractor is required to pay noncontracted providers at Medicaid FFS rates for all properly authorized, medically necessary services for which a clean claim is submitted.

Noncontracted providers must comply with all applicable authorization requirements of the Contractor and uniform billing requirements.

23. Section 3.26 Excluded Services, D is revised.

D. HIDE SNP is responsible for making referrals to the Community Transition Services program when an enrollee meets program criteria as defined in the Community Transition services chapter of the Michigan Medicaid Provider Manual. In the absence of a Community Transition Services Agency in the beneficiary’s geographic region, the HIDE SNP shall support transitions from nursing facilities and institutions to the community within the scope of the HIDE-SNPs plan benefit package/available services.

24. Section 4.1 Network Adequacy, A. is revised.

A. Contractor must maintain a Provider Network sufficient to provide all Enrollees with access to the full range of Covered Services, including the appropriate range of preventive, primary care, and specialty services, behavioral health services, other specialty services, and all other services required in 42 C.F.R. §§ 422.112, 423.120, 438.52(b) and 438.206, Medicaid Provider Manual, HIDE SNP 1915 b/c waiver applications and under this Contract taking into consideration:

a. The anticipated number of Enrollees.

b. The expected utilization of services, considering the characteristics and health care needs of Contractor’s Enrollees.

c. The number and types (in terms of training, experience, and specialization) of providers required to furnish the Covered Services.

d. The number of network providers who are not accepting new patients.

e. The geographic location of providers and Enrollees, considering distance, travel time, the means of transportation ordinarily used by Enrollees, and whether the location provides physical access for Enrollees with disabilities.

f. The communication needs of Enrollees; and

g. The cultural and ethnic diversity and demographic characteristics of Enrollees.

25. Section 4.4 Medicaid Provider and LTSS Provider Network Standards, C is revised and D is hereby removed.

C. At a minimum, for each county in the service area, for services provided in Enrollee’s home, Contractor must have at least two (2) available providers for each provider type with sufficient capacity to accept Enrollees and otherwise ensure that the Enrollee has a choice of providers.

26. Section 5.1 Management Information System (MIS) Capabilities, C. b. viii is hereby removed.

27. Section 5.5 PCP Submission File, A and B are hereby removed.

28. Section 5.8 Electronic Exchange of Enrollee-Level Information, A. a is revised.

a. Contractor must ensure capabilities to electronically send applicable assessment data to MDHHS for purposes of care coordination (e.g. LOCD, interRAI, Personal Care Assessment, etc.).

29. Section 6.2 Local Health Departments and CSHCS Coordination, A. is revised and B. is hereby removed.

A. Contractor must coordinate care for CSHCS Enrollees in Contractor’s Service Area. The coordination must include the following:

a. Data sharing

b. Communication on development of Individual Care Plans

c. Reporting requirements

d. Quality assurance coordination

e. Grievance and Appeal resolution

f. Dispute resolution and

g. Health Care Transition for Enrollees initiated prior to age 14 and continuing into young adulthood, including transition readiness assessments and family-centered plans.

30. Section 6.4 Collaboration with PIHPs, C is hereby removed.

31. Section 6.7 Integrated Care Team Responsibilities, A. a is revised.

a. Ensure the Individualized Care Plan (ICP) is developed, implemented, and revised according to the Person-Centered Planning Process as that term is defined and described in 42 CFR §§441.301(c), 441.725(a) and 441.540(a) together with the Enrollee’s stated goals including making whatever accommodations are appropriate for individuals whose disabilities create obstacles to full participation with the ICT;

32. Section 6.8 HIDE SNP Care Coordinators, F. a. vi is revised.

vi. Be knowledgeable about risk factors and indicators of and resources to respond to and report abuse, neglect, exploitation, and other critical incidents;

33. Section 6.12 Continuity of Care, A, d. i is hereby removed.

34. Section 7.6 Performance Measurement, A, D, and K are revised.

A. In addition to meeting all CMS requirements on performance measurement for HIDE SNP plans, Contractor must perform and report the quality and utilization measures identified by CMS and MDHHS for HIDE SNP program and as articulated in this Contract and as outlined in Appendix F.

D. For all standard national performance measures, Contractor must obtain an independent validation of its findings by a recognized entity, e.g., NCQA-certified auditor, as approved by CMS and MDHHS. MDHHS (or its designee) will perform an independent validation of at least a sample of Contractor’s findings.

K. Contractor’s failure to consistently submit complete and accurate performance measure data and participate in MDHHS performance measure data quality activities and reviews in accordance with MDHHS standards may impact scoring for Quality Withholds as referenced in Appendix G and subject Contractor to MDHHS contract remedies including but not limited to monetary Sanctions and other Sanctions, such as corrective action.

35. Section 7.12 QI for Utilization Management Activities is renamed to 7.12 Clinical Practice Guidelines.

36. Section 7.15 MDHHS Directed Medicaid Quality Withhold/Performance Incentive Program, A and B are revised.

A. In support of MDHHS’ commitment to quality improvement, innovation, and operational excellence of Medicaid benefits and services, MDHHS will withhold a percentage of the Medicaid Capitation Payment from Contractor and make the return of these withheld funds contingent upon Contractor meeting certain quality and performance metrics.

B. Beginning calendar year 2027, MDHHS will withhold 2.00% of the Capitation Payment.

MDHHS reserves the right to revise the withhold percentage ahead of each fiscal period.

37. Section 8.1 Cost Sharing for Medicaid Services is revised as follows.

Since the capitation rate paid to Contractor includes Medicaid payment of Medicare cost sharing, Contractor will ensure the following:

A. For Medicaid services, Contractor will not charge cost sharing to Enrollees.

B. Contractor must waive Medicaid cost sharing.

C. Enrollee Contribution to Care Amounts:

a. The amount an enrollee must pay toward Medicaid Nursing Facility care is known as the PPA, and is calculated for every individual receiving Nursing Facility Care by the local MDHHS office, although not every eligible individual will have a PPA.

b. MDHHS will provide information to the HIDE SNP that identifies Enrollees who are required to pay a PPA and the amount of the obligation via 834 files.

c. Medicaid Component of MDHHS Capitation Payments to the HIDE SNP for Enrollees who are required to pay a PPA will be net of the monthly PPA.

d. It is the responsibility of the Nursing Facility provider to collect the PPA from Enrollees, and the HIDE SNP must reduce reimbursements to Nursing Facility providers equal to the PPA amount each month.

e. PPA may be prorated for stays less than a full month. Proration is based on the facility’s Medicaid daily rate charged to the Enrollee per day until the PPA is exhausted.

38. Section 8.2 Protecting Member from Liability for Payment, A is revised.

A. In accordance with 42 CFR §438.106 and 42 CFR §447.15, Contractor must ensure that its Members are not held liable for payment for any services provided under this Contract other than Member patient pay liability towards Nursing Facility Care and Part D cost sharing.

39. Section 8.3 Cost Sharing Protections, A is revised.

A. Except with regard to Part D cost sharing, Contractors will pay providers for Medicare-covered services, the amount of cost sharing for which Michigan Medicaid is liable based on the submission of the Medicare claim, without requiring submission of a second claim for cost sharing.

40. Section 9.1 General Provisions, F and F.c.ii.(b) are revised.

F. Contractor must give written notice of termination of a provider irrespective of whether the termination was for cause or without cause. See 42 CFR §§422.111(e) and 438.10(f).

Contractor must make a good faith effort to give notice of a for-cause termination of a provider within the timeframes required. For all terminations, Contractor must meet the following requirements:

(b) Phone call attempts must be documented in the EHR.

41. Section 9.2 Services Not Subject to Prior Approval is revised as follows.

A. Emergency Medical Conditions: Contractor will assure coverage of Emergency Medical Conditions and Urgent Care Services. Contractor must not require prior approval for the following services:

a. Any services for Emergency Medical Conditions as defined in 42C.F.R §§ 422.113(b)(1) and 438.114(a) (which includes emergency behavioral health care);

b. Urgent Care sought outside of the Service Area;

c. Urgent Care under unusual or extraordinary circumstances provided in the Service

Area when the contracted medical provider is unavailable or inaccessible;

d. Family planning services;

e. Out-of-area renal dialysis services.

B. Communicable Disease Services; Contractor must cover or pay applicable Medicare cost sharing for Enrollees to receive treatment services for communicable diseases from local health departments without prior authorization: including HIV/AIDS, Sexually Transmitted Infections (STI), tuberculosis, and vaccine-preventable communicable diseases.

C. Non-Emergent Family Planning Services: Contractor must allow Enrollees to seek family planning services, drugs, supplies and devices without prior authorization.

42. Section 9.3 Authorization of Services, B, G.a, G.b are revised and J and K are added.

B. Contractor must ensure that a Contractor representative and a behavioral health provider are available twenty-four (24) hours a day for timely authorization of Medically Necessary Services, including, if necessary, the transfer of the Enrollee who presented to an emergency department with an Emergency Medical Condition that has been Stabilized. If

Contractor waives or otherwise does not require prior authorization of such services, 24 hour coverage for authorization is not required.

G.a. For standard authorization decisions, provide Notice as expeditiously as the Enrollee’s health condition requires and no later than seven (7) calendar days after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension will only be allowed if:

G.b. For expedited service authorization decisions, where the provider indicates or Contractor determines that following the standard timeframe in Section 37G could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, Contractor must make a decision and provide Notice as expeditiously as the Enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension will only be allowed if:

J. Contractor must report prior authorization data from the following 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:

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

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

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

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

e. 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;

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

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

h. 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;

i. 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.

K. 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.

43. Section 9.5 Emergency and Post-Stabilization Care and Coverage, E.c is revised.

c. Record summary information about Emergency Medical Conditions and Urgent Care services in the Enrollee EHR no more than twenty-four (24) hours after the PCP or ICT is notified, and a full report of the services provided within two (2) business days.

44. Section 10.1 Enrollee Service Representatives (ESRs), L is revised.

L. ESRs must have access to the Enrollee’s EHR and an electronic Provider and Pharmacy Directory.

45. Section 10.2 Enrollee Service Telephone Responsiveness, F is revised.

F. Contractor must ensure that if care management needs are identified for an Enrollee that the ESR facilitating the Enrollee’s issue has access to and knows how to read and interpret the Enrollee ICPs. Contractor must ensure that follow-up is timely and appropriate to assure the Enrollee’s health and welfare.

46. Section 11.1 General Requirements, A, F is revised and E and I are removed.

A. Contractor is subject to rules governing Marketing, Outreach, and Enrollee Communications as specified under Section 1851(h) of the Social Security Act; 42 C.F.R. § 422.111, Part 422 Subpart V, § 423.120(b) and (c), § 423.128, Part 423 Subpart V, and §

438.10 et seq.; and the Medicare Communications and Marketing Guidelines (MCMG), MDHHS Marketing Requirements for HIDE SNPs with the following additional requirements or clarifications:

F. Contractor must receive prior approval of designated marketing and Enrollee Communications materials in categories of materials that MDHHS requires to be prospectively reviewed.

H. Contractor will submit materials as directed by CMS and MDHHS for review by the appropriate agency via the CMS Health Plan Management System (HPMS) Marketing Review Module.

47. Section 11.5 Requirements for the Submission, Review, and Approval of Materials, A is revised and B and C are added.

A. Contractors must receive prior approval via HPMS of marketing and Enrollee Communications materials as designated by MDHHS. MDHHS may conduct additional types of review of Contractor Marketing, Outreach, and Enrollee Communications activities, including, but not limited to:

B. The multi-plan submission process in HPMS is not applicable to D-SNP-only contracts. In addition, when a third party, such as a pharmacy benefit manager (PBM), creates and distributes enrollee-specific materials on behalf of multiple organizations, it is not acceptable to use the material ID for another organization or a Y number for materials the third-party provides to D-SNP enrollees in D-SNP-only contracts. The material must be submitted in HPMS using a separate material ID number for the D-SNP-only contract and that material ID number must be included in the material.

C. Materials that contain reference to Michigan Medicaid program benefits or any Michigan Medicaid program must be submitted to HPMS for MDHHS review and approval prior to use.

MDHHS may request Ad Hoc reports and/or information from Contractor. Contractor must fulfill these requests within thirty (30) calendar days of the date of the agreed upon business requirements unless otherwise agreed upon by MDHHS and Contractor.

48. Section 11.6 Integrated Enrollee Materials, A, B, and C.i are revised.

A. Contractor must comply with integrated materials required of Applicable Integrated Plans, in a format to be determined by MDDHS, to include:

a. Annual Notice of Change (ANOC) - Contractor must send a state-specific ANOC cover letter to enrollees transitioning from an Integrated Care Organization or a Coordination Only D-SNP operated by Contractor to Contractor’s HIDE SNP.

MDHHS will provide a template for the cover letter.

b. Member Handbook

c. Summary of Benefits (SOB)

d. Provider and Pharmacy Directory (PPD)

e. List of Covered Drugs (LOCD)

f. Member ID Card

B. Contractor must send a state-specific ANOC cover letter to enrollees transitioning from the ICO to the HIDE SNP. MDHHS will provide the cover letter directly to the HIDE SNPs around the time of release of other marketing materials.

C. i. A Member Handbook (Evidence of Coverage), or a distinct and separate Notice on how to access the Member Handbook online and how to request a hard copy.

49. Section 11.8 Use of the MI Coordinated Health (MICH) Program Logo is revised as follows.

A. All use of the MICH program logo must meet the following requirements:

a. Contractors must submit materials that contain the MICH program logo for MDHHS review.

b. The MICH program logo will not be used to imply sponsorship or endorsement on materials distributed by Contractor.

c. The MICH program logo will not be used in any manner that may possibly disparage, bring into disrepute, or negatively reflect on the MICH program or in connection with any products or services that may possibly diminish or damage the goodwill of the MICH program or MDHHS.

d. Contractor may not include the MICH program logo on educational materials.

e. Contractor may not use the MICH program logo on business cards.

f. The MICH program logo provided by the State to Contractors cannot be altered without the express permission of MDHHS.

g. The MICH program logo must not be used as a feature or design element, or be incorporated into any other service mark or logo.

h. The MICH program logo must stand by itself so as to avoid unintended associations with any other objects, including, but not limited to, text, photographs, illustrations, borders, and edges. The width of the blank space surrounding the logo must be equal to 1/3 of the size of the symbol that is displayed (e.g., if the symbol is 30 pixels across, it must have 10 pixels of blank space above, below and on each side). The logo and Contractor’s logo must retain their natural proportional size and must not appear stretched, distorted, or pixelated. The MICH program logo must appear in color whenever Contractor’s logo is displayed in color on the same document or material.

i. Contractor’s downstream contractors and related entities may not use the MICH program logo unless the document has been approved through HPMS or the State approved process.

B. The State of Michigan, through MDHHS, retains the right to change these guidelines at any time.

50. Section 11.10 Member Handbook Requirements, A is revised.

A. The Member Handbook must include the following items, consistent with model materials provided by MDHHS and CMS:

51. Section 11.11 Requirements for the Provider and Pharmacy Directory, A.d is revised.

d. Contractor must ensure an up-to-date copy is available on Contractor’s website, updated no later than 30 calendar days after Contractor receives updated provider information, consistent with the requirements at 42 C.F.R. §422.411(b)(3);

422.2267(e)(11); 423.128(d); 438.10(h)(3); and that the provider network information included in a paper provider directory is updated at least monthly.

i. When there is a significant change to the network, Contractor must provide Notice to Enrollees, as specified in Chapter 4 of the Medicare Managed Care Manual.

ii. Consistent with Section 9.1F of this Contract and 42 C.F.R. §422.111(e) and 422.2267(e)(12), Contractor must make a good faith effort to provide written Notice of termination of a contracted provider or pharmacy at least thirty (30) calendar days before the termination effective date to all Enrollees who regularly use the provider or pharmacy’s services; irrespective of whether the termination was for cause or without cause.

iii. If a contract termination involves a PCP, all Enrollees who are patients of that PCP must be notified.

52. Section 12.1 General Requirements, B, E.a, E.g, F.g are revised.

B. Consistent with State policy, Contractor’s Integrated and Unified Grievance and Appeal system and processes must be in compliance with the terms of 42 CFR §§ 422.629 – 422.634, 438.210, 438.400, and 438.402 as may be amended (the “Unified G&A

Regulations”), and MCL 500.2213, (the Unified Grievance and Appeal System”). This includes without limitation:

E. a. Contractor must administer internal integrated appeal procedures according to the requirements of MCL 500.2213, 42 CFR 438.400 – 438.424 (Subpart F) and 42 CFR §§

422.629 – 422.634.

E. g. Contractor must make a determination on standard integrated Appeals as expeditiously as the member’s health requires, but in all cases not later than 30 calendar Days after an Appeal is received from an Enrollee and 72 hours for expedited integrated appeals according to 42 CRF 422.633(f). Integrated appeals may be extended for a period of time that must not exceed 14 Days if (1) the Enrollee requests the extension or (2) Contractor shows that there is need for additional information and how the delay is in the Enrollee’s interest. Contractor may not extend the time frame for appeal decisions other than as described in this Section.

F. g. Contractor must allow Enrollees 65 Days from the date of the Adverse Benefit Determination notice in which to file an integrated Appeal.

53. Section 12.3 Notice to Enrollees of Adverse Benefit Determination, A.b is revised.

A. b. For denial of payment, within the time frames specified in 42 CFR §422.631(d).

54. Section 12.4 CSHCS Appeals, C is revised.

C. When reviewing appeals for Enrollees in CSHCS, Contractor must utilize an appropriate subspecialist provider to review decisions to deny, suspend, terminate, or limit subspecialist provider services.

55. Section 12.6 Integrated Grievances, A.a is revised and D is added.

a. Contractor must administer internal integrated grievance procedures according to the requirements of MCL 500.2213, 42 CFR 438.400 – 438.424 (Subpart F) and 42 CFR §422.630.

D. HIDE SNP Billing Issues and Complaint Resolution

a. When a complaint or billing issue is received by MDHHS, MDHHS will initiate contact with the Contractor.

b. A beneficiary complaint is any situation in which a beneficiary or beneficiary's representative expresses a concern about care or services provided. Types of complaints sent from MDHHS include, but are not limited to, any access to care issue, including vision, dental, behavioral health, routine healthcare, transportation assistance, and/or prescriptions.

i. Within 24-48 hours of receipt of complaint, Contractor must provide MDHHS with an update on the resolution process or a description of the issue.

c. A billing issue is any situation in which a beneficiary has received a bill for services they believe should have been covered by Medicaid. These issues sent from MDHHS may include billing statements, collections notices, and/or written descriptions of the issue.

i. Contractor must provide to MDHHS an update on the resolution process or the full resolution within 2 weeks of receipt.

d. A provider complaint is any situation in which a provider expresses a concern about the business operations of Contractor, not including billing issues.

i. Contractor must provide MDHSHS with an update regarding the resolution of provider complaints within 2 weeks of receipt. (repeat for billing but allow 30 days.)

e. A provider complaint is any situation in which a provider expresses a concern about the timeliness or accuracy of payment by Contractor to the provider.

56. Section 13.1 Timely Provider Payments, G is revised.

G. Contractor must ensure that the date of receipt is the date 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.

57. Section 13.5 Different Types of Provider Payments, J is added.

J. Payment Resolution

a. Contractor must develop and maintain an effective Provider Appeal process to promptly resolve Provider billing disputes and other issues.

b. Contractor must cooperate with Providers who have exhausted Contractor’s Appeal process by entering into arbitration or other alternative dispute resolution processes.

c. Arbitration and Rapid Dispute Resolution for Hospital Providers

58. Section 14.7 Payment Resolution is renamed to 14.7 Hospital Access Agreement, A, B and C are removed and D is revised.

D. Contractor must comply with the provisions of the Hospital Access Agreement executed by MDHHS and the hospitals. See MSA-01-28-FinalBulletin-Payment between Noncontracting Hospitals and Medicaid Health Plans.

59. Section 16.1 General, A is revised.

A. A Critical Incident is any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety, or well-being of an Enrollee, including Provider Preventable Conditions as defined by the National Quality Forum.

60. Section 17.2 Fraud, Waste, and Abuse Program, J.a and M.b.ii are revised.

J. a. Contractor must not knowingly have a director, officer, partner, managing employee or person with beneficial ownership of more than 5% of the Contractor’s equity who has been or currently debarred or suspended from participating in procurement activities under the

Federal Acquisition Regulation or from participating in non-procurement activities under regulations…