Attachment B - Scope of Work United Behavioral Health, Inc.

Effective 7/1/2025

Attachment B - Scope of Work

Article 1: Introductory Provisions

1.1 Parties

(A) This Contract is between the State of Utah, acting by and through its Department of Health and Human Services (DHHS) which is the Single State agency as specified in the State Plan, hereinafter referred to as “Department” and United Behavioral Health, Inc., hereinafter referred to as “Contractor.”

Together, the Department and Contractor shall be referred to as the “Parties.”

(B) In compliance with 42 CFR § 438.602(i), the Contractor agrees that for the duration of this Contract, the Contractor shall not be located outside of the United States. Additionally, no Claims paid by the Contractor to a Network Provider, Non-Network Provider, Subcontractor, or financial institution located outside of the United States are considered in the development of actuarially sound Capitation Rates.

1.2 Notices

Any notices that are not otherwise specified in the Contract, but are permitted or required under this Contract, shall be in writing and shall be transmitted by:

(a) certified or registered United States mail, return receipt requested;

(b) personal delivery;

(c) expedited delivery; or

(d) electronic delivery to authorized representative(s) of the Contractor.

Such notices shall be addressed as follows:

Department (if by mail):

Utah Department of Health and Human Services

Division of Integrated Healthcare

Effective 7/1/2025

Director, Office of Managed Healthcare

P.O. Box 143108

Salt Lake City, UT 84114

Department (if in person):

Utah Department of Health and Human Services

Division of Integrated Healthcare

Director, Office of Managed Healthcare

288 North 1460 West

Salt Lake City, UT 84114

Contractor:

United Behavioral Health, Inc.

12921 S Vista Station Blvd #200

Draper, UT 84020

In the event that the above contact information changes, the party changing the contact information shall notify the other party, in writing, of such change.

1.3 Service Area

1.3.1 Service Area, Generally

(A) The Service Area is the specific geographic area within which the Medicaid Eligible Individual must reside to enroll with the Contractor. The Service Area for this Contract is Tooele County.

(B) The Contractor shall provide adequate assurances and supporting documentation that the Contractor has the capacity to serve the expected enrollment in the Service Area.

Effective 7/1/2025

1.3.2 Residency in Service Area

The Department has sole discretion to determine whether an Enrollee resides in a particular Service Area.

1.3.3 Mandatory/Voluntary Enrollment Service Areas

Medicaid Eligible Individuals with reported county code(s) in the Service Area are mandatorily enrolled with the Contractor.

Article 2: Definitions

For purposes of this Contract, the following definitions apply, unless otherwise specified:

Abuse means Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care. It also includes Medicaid Member practices that result in unnecessary cost to the Medicaid program.

Accountable Care Organization (ACO) means a Utah MCO that contracts with the Department to provide medical services to its Enrollees.

Actuary means an individual who meets the qualification standards established by the American Academy of Actuaries for an Actuary and follows the practice standards established by the Actuarial Standards Board. In this Contract, Actuary refers to an individual who is acting on behalf of the State when used in reference to the development and certification of Capitation Rates.

Adult Expansion Population means the eligible membership limited to adults with or without dependent children, earning up to 133% (with an additional 5% disregard) of the federal poverty level.

Advance Directive means a written instruction such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.

Effective 7/1/2025

Adverse Benefit Determination means:

(1) the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for Medical Necessity, appropriateness, setting, or effectiveness of a Covered Service;

(2) the failure to reach a decision on a Service Authorization Request within the required timeframes;

(3) the reduction, suspension, or termination of a previously authorized service;

(4) the denial, in whole or in part, of payment for a service, but not if the denial, in whole or in part, of a payment for a service is solely because the Claim does not meet the definition of a Clean Claim;

(5) the failure to provide services in a timely manner, defined as failure to meet performance standards for appointment waiting times specified in Article 10.5 of this attachment;

(6) the failure of the Contractor to act within the timeframes established for resolution and notification of Grievances and Appeals;

(7) for a resident of a rural area with only one MCO, the denial of an Enrollee’s request to exercise the Enrollee's right to obtain services outside the network; or

(8) the denial of an Enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other Enrollee financial liabilities.

Aggrieved Person means an Aggrieved Person as defined by Utah Administrative Code R410-14-2.

Appeal means a review by an MCE of an Adverse Benefit Determination.

Capitation means the reimbursement arrangement in which a fixed rate of payment per Enrollee per month is made to the Contractor for the performance of all of the Contractor’s duties and obligations pursuant to this Contract.

Effective 7/1/2025

Capitation Payment means the payment the Department makes periodically to the Contractor on behalf of each Enrollee for the provision of Covered Services under the Contract and based on the actuarially sound Capitation Rate. The Department makes the payment regardless of whether the particular Enrollee receives services during the period covered by the payment.

Capitation Rate means the rate negotiated between the Contractor and Department for each Medicaid eligibility group or Capitation Rate cell.

Centers for Medicare and Medicaid Services (CMS) means the agency within the Federal Department of Health and Human Services (HHS) that administers the Medicare, Medicaid, and CHIP programs and works with states to administer the Medicaid and CHIP programs.

CHIP means the Children’s Health Insurance Program authorized by Title XXI of the Social Security Act.

Claim means:

(1) a bill for services;

(2) a line item of services; or

(3) all services for one Enrollee within a bill.

Clean Claim means a Claim that can be processed without obtaining any additional information from the Provider of the service or from a Third Party. It includes a Claim with errors originating from the Contractor’s claims system. It does not include a Claim from a Provider who is under investigation for Fraud or Abuse or a Claim under review for Medical Necessity.

Cold-Call Marketing means any unsolicited personal contact by the Contractor, its employees, Network Providers, agents, or Subcontractors with a Potential Enrollee for the purposes of Marketing.

Comprehensive Risk Contract means a risk contract between the State and an MCO that covers comprehensive services, that is, inpatient hospital services and any of the following services, or any three or more of the following services:

(1) outpatient hospital services;

Effective 7/1/2025

(2) rural health clinic services;

(3) Federally Qualified Health Center (FQHC) services;

(4) other laboratory and X-ray services;

(5) Nursing facility (NF) services;

(6) Early and periodic screening, diagnostic, and treatment (EPSDT) services;

(7) family planning services;

(8) physician services; and

(9) home health services.

Confidential Data means any non-public information maintained in an electronic format used or exchanged by the Parties in the course of the performance of this contract whose collection, disclosure, protection, and disposition is governed by State or federal law or regulation, particularly information subject to the Gramm- Leach-Bliley Act, the Health Insurance Portability and Accountability Act, and other equivalent State and federal laws. Confidential Data includes, but is not limited to, Social Security numbers, birth dates, medical records, Medicaid identification numbers, medical Claims and Encounter Data.

Convicted means a judgment of conviction entered by a federal, state, or local court, regardless of whether an appeal from that judgment is pending.

Covered Services means services and supplies identified in Attachment C of this Contract that the Contractor is required to provide and pay for pursuant to the terms of this Contract.

Credentials Verification Organization (CVO) means a company that helps healthcare organizations verify the qualifications of their medical providers. CVOs specialize in primary source verifications (PSV) and can help with credentialing, payer/provider enrollment, licensure application and sanctions monitoring, background screening, and policy and procedure consulting.

Crossover Claim means a Claim for an Enrollee who is also a Medicare beneficiary where Medicare pays a portion of the claim and Medicaid is billed for any remaining deductible and/or coinsurance or copayment amounts.

Effective 7/1/2025

Date of Discovery means the date which identification by any State Medicaid agency official or other State official, the federal government, the Provider, or the Contractor of an Overpayment and the communication of that Overpayment finding or the initiation of a formal recoupment action without notice as described in 42 CFR § 433.316.

Disclosing Entity means a Medicaid Provider (other than an individual practitioner or group of practitioners), or a Fiscal Agent. For purposes of the Contract, Disclosing Entity means the Contractor.

Division of Professional Licensing (DOPL) means an agency within the Utah Department of Commerce which administers and enforces specific laws related to the licensing and regulation of certain occupations and professions.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program means the federally mandated program as defined in 42 CFR § 441, subpart B, that provides comprehensive and preventive health care services for children.

Electronic Resource Eligibility Product (eREP) means the computer support system used by eligibility workers to determine Medicaid eligibility and store eligibility information.

Eligibility Transmission means the 834 Benefit Enrollment and Maintenance File.

Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(1) placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;

(2) serious impairment to bodily functions; or

(3) serious dysfunction of any bodily organ or part.

Emergency Services means covered inpatient and outpatient services that are furnished by a Provider that is qualified to furnish these services and that are needed to evaluate or stabilize an Emergency Medical Condition.

Effective 7/1/2025

Encounter means an individual service or procedure provided to an Enrollee that would result in a Claim.

Encounter Data means the information relating to the receipt of any item(s) or service(s) by an Enrollee that is subject to the requirements of 42 CFR §§ 438.242 and 438.818.

Enrollee means any Medicaid Eligible Individual whose name appears on the Department’s Eligibility Transmission as enrolled with the Contractor.

Enrollees with Special Health Care Needs means Enrollees who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by adults and children generally.

Exclusion or Excluded means the temporary or permanent barring of an individual or entity from participation in a Federal Health Care Program and that services furnished, ordered or prescribed by that individual or entity are not paid for under any Federal Health Care Program.

External Quality Review (EQR) means the analysis and evaluation of information by an EQRO of aggregated information on quality, timeliness, and access to the health care services that an MCE, or its Network Providers, furnish to its Enrollees.

External Quality Review Organization (EQRO) means an organization that meets the competence and independence requirements set forth in 42 CFR § 438.354, and performs EQR, other EQR-related activities set forth in 42 CFR § 438.358, or both.

Federal Acquisition Regulation (FAR) means the regulation found at Title 48 of the Code of Federal Regulations, Chapter 1, Parts 1 through 53.

Federal Department of Health and Human Services (HHS) means the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.

Federal Financial Participation (FFP) means, in accordance with 42 CFR § 400.203, the federal government’s share of a state’s expenditures under the Medicaid

Effective 7/1/2025 program and is determined by comparing a state’s per capita income to the national average.

Federal Health Care Program means:

(1) any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5, United States Code) of the Social Security Act; or

(2) any State Health Care Program, as defined in Section 1128(h) of the Social Security Act.

Federally Qualified Health Center (FQHC) means a community-based organization that qualifies for funding under Section 330 of the Public Health Service Act (PHS), and that provides comprehensive primary care and preventive care, including health, oral, and mental health/substance use services to persons of all ages, regardless of their ability to pay or their health insurance status.

Federally Qualified HMO means an HMO that CMS has determined is a qualified HMO under section 1310(d) of the Public Health Services Act.

Fee for Service (FFS) means the Medicaid service delivery system under which services are billed directly to and are paid directly by the Division of Integrated Healthcare based on an established fee schedule.

Fiscal Agent means a contractor that processes or pays vendor Claims on behalf of the Department or Contractor.

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themselves or some other person. It includes any act that constitutes Fraud under applicable federal or State law.

Grievance means an expression of dissatisfaction about any matter other than an Adverse Benefit Determination. Grievances may include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a Provider or an employee, failure to respect the Enrollee’s rights regardless of whether remedial action is requested.

Effective 7/1/2025

Grievance and Appeal System means the processes the Contractor implements to handle Appeals of an Adverse Benefit Determination and Grievances, as well as the processes to collect and track information about them.

Health Insuring Organization (HIO) means a county operated entity that in exchange for Capitation Payments, covers services for beneficiaries:

(1) through payments to, or arrangements with, providers;

(2) under a Comprehensive Risk Contract with the State; and

(3) meets the following criteria:

(i) first became operational prior to January 1, 1986; or

(ii) is described in section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985 (as amended by section 4734 of the Omnibus Budget Reconciliation Act of 1990 and section 205 of the Medicare Improvements for Patients and Providers Act of 2008).

Healthcare Effectiveness Data and Information Set (HEDIS) means a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance developed and maintained by NCQA.

Healthy Outcomes Medical Excellence (HOME) means the MCO under contract with the Department that is designed to provide services to children and adults with a developmental disability and mental illness and/or behavioral problems.

HOME covers both physical and behavioral health services for its enrollees.

Home and Community Based Waiver Services means services, not otherwise furnished under the State’s Medicaid plan, that are furnished under a waiver of statutory requirements granted under the provisions of 42 CFR § 441, subpart G.

These services cover an array of home and community-based services that are cost-effective and necessary for an individual to avoid institutionalization.

Hospital-Acquired Condition (HAC) means a condition occurring in any inpatient hospital setting, defined as a HAC by the Secretary of HHS under Section 1886(d)(4)(D)(iv) of the Social Security Act for purposes of the Medicare program identified in the State Plan as described in Section 1886(d)(4)(D)(ii) and (iv) of the

Effective 7/1/2025

Act; other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Indian means any individual defined at 25 USC §§ 1603(13), 1603(28) or 1679(a), or who has been determined eligible as an Indian under 42 CFR § 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian Health Care Providers.

Indian Health Care Provider (IHCP) means a health care program, operated by Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) as those terms are defined in Section 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603).

Indirect Ownership Interest means an Ownership Interest in an entity that has an Ownership Interest in the Contractor. This term includes an Ownership Interest in any entity that has an Indirect Ownership Interest in the Contractor.

Institution for Mental Diseases (IMD) means a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for individuals with intellectual disabilities is not an institution for mental diseases.

K Children means Enrollees identified in the Eligibility Transmission as being in Rate Cell K.

Legacy Medicaid Population means the eligible membership groups of children 0- 18, K Children, pregnant women, blind and disabled, aged, members eligible under the cancer program, and adults on Family Medicaid programs.

List of Excluded Individuals/Entities (LEIE) means the federal HHS Inspector General’s database regarding individuals and entities currently Excluded by the HHS Inspector General from participation in Medicare, Medicaid, and all other Federal Health Care Programs. Individuals and entities who have been reinstated are

Effective 7/1/2025 removed from the LEIE. The LEIE website is located at https://exclusions.oig.hhs.gov.

Local Mental Health/Substance Abuse Authority means the county authority responsible to provide directly or by subcontract mental health and substance use disorder services to residents of the authority’s county or counties in accordance with Utah Code Ann. § 17-43-301 and § 17-43-201.

Long-term Services and Supports (LTSS) means services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of their choice, which may include the individual’s home, a worksite, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting.

Managed Care Entity (MCE) means MCOs, PIHPs, PAHPs, PCCMs, and HIOs. The Contractor is a PIHP.

Managed Care Organization (MCO) means an entity that has, or is seeking to qualify for, a Comprehensive Risk Contract, and that is:

(1) a federally qualified HMO that meets the Advance Directives requirements of 42 CFR § 489, subpart I; or

(2) any public or private entity that meets the Advance Directives requirement of 42 CFR § 489, subpart I and is determined by the Secretary of HHS to also meet the following conditions:

(i) makes the services it provides to its Enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid or CHIP Members within the area served by the entity; and

(ii) meets the solvency standards of 42 CFR § 438.116.

Managed Care Program means a managed care delivery system operated by the State as authorized under sections 1915(a), 1915(b), 1932(a), or 1115(a) of the Social Security Act.

Effective 7/1/2025

Managed Care Quality Strategy means, in accordance with 42 CFR § 438.340, the Department's written quality strategy for assessing and improving the quality of health care and services furnished by a MCO, PIHP, PAHP, or PCCM entity.

Managing Employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of the Contractor.

Marketing means any communication from the Contractor, its employees, Network Providers, agents or Subcontractors to a Potential Enrollee that can reasonably be interpreted to influence the Potential Enrollee to enroll in the Contractor’s Medicaid product, or either to not enroll in, or to disenroll from another PMHP's Medicaid product.

Marketing Materials means materials that are produced in any medium, by or on behalf of the Contractor, its employees, affiliated Providers, agents or Subcontractors to a Potential Enrollee that can reasonably be intended to market to Potential Enrollees.

Medicaid means the medical assistance program authorized under Title XIX of the Social Security Act.

Medicaid Eligible Individual or Medicaid Member means any individual who has been deemed eligible for Medicaid benefits by DHHS or the Utah Department of Workforce Services (DWS).

Medicaid Fraud Control Unit (MFCU) means the statutorily authorized criminal investigation unit in the Utah Attorney General’s Office charged with investigating and prosecuting Medicaid Fraud.

Medicaid Information Bulletin (MIB) means the official, periodic publication of the Department. The purpose of MIBs is to provide policy information to Medicaid providers including updates to the Utah Medicaid Provider Manual.

Medical Loss Ratio (MLR) means the calculation the Contractor is required to quantify and report to the Department pursuant to 42 CFR § 438.8.

Medically Necessary or Medical Necessity means medically necessary service as defined by Utah Administrative Code R414-1-2(18).

Effective 7/1/2025

Member Services means a method of assisting Enrollees in understanding Contractor policies and procedures, facilitating referrals to participating specialists, and assisting in the resolution of problems and Enrollee complaints. The purpose of Member Services is to improve access to services and promote Enrollee satisfaction.

National Committee for Quality Assurance (NCQA) means a private, non-profit organization dedicated to improving health care quality by evaluating and reporting on the quality of managed care and other health care organizations in the United States. NCQA developed HEDIS and maintains and updates a database of HEDIS results.

National Practitioner Data Bank (NPDB) means the database operated by HHS that contains medical malpractice payment and adverse action reports on health care professionals. The NPDB assists in promoting quality health care and deterring fraud and abuse within health care delivery systems.

Network Provider means any provider, group of providers, or entity that has a Network Provider agreement with the Contractor, or a Subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render Covered Services as a result of the Contract. A Network Provider is not a Subcontractor by virtue of the Network Provider agreement.

Non-Network Provider means any individual, corporate entity, or any other organization that is engaged in the delivery of health care services, is legally authorized to do so by the state in which it delivers the services and does not have a Network Provider agreement or employment agreement with the Contractor.

Notice of Adverse Benefit Determination means written notification to an Enrollee and written or verbal notification to a Provider when applicable, of an Adverse Benefit Determination that will be taken by the Contractor.

Notice of Appeal Resolution means written notification to an Enrollee, and a Provider when applicable, of the Contractor’s resolution of an Appeal.

Office of Recovery Services (ORS) means an office within DHHS.

Effective 7/1/2025

Other Disclosing Entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, or XX of the Social Security Act. This includes:

(1) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare;

(2) Any Medicare intermediary or carrier; and

(3) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Social Security Act.

Other Provider Preventable Condition means a condition occurring in a health care setting that meets the following criteria:

(1) is identified in the State Plan;

(2) has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines;

(3) has a negative consequence for the Enrollee;

(4) is auditable; and

(5) includes, at a minimum, wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

Overpayment means any payment made to a Provider by a Managed Care Program to which the Provider is not entitled to under Title XIX of the Social Security Act or any payment to a Managed Care Program by the Department to which the Managed Care Program is not entitled to under Title XIX of the Social Security Act.

Effective 7/1/2025

Ownership Interest means the possession of equity in the capital, the stock, or the profits of the Contractor.

Performance Improvement Project (PIP) means a project designed to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in clinical and non-clinical areas that are expected to have a favorable effect on the health outcomes and Enrollee satisfaction.

Person with an Ownership or Control Interest means a person or corporation that:

(1) has an Ownership Interest totaling 5 percent or more in the Contractor;

(2) has an Indirect Ownership Interest equal to 5 percent or more in the Contractor;

(3) has a combination of direct and Indirect Ownership Interests equal to 5 percent or more in the Contractor;

(4) owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the Contractor if that interest equals at least 5 percent of the value of the property or assets of the Contractor;

(5) is an officer or director of the Contractor including the Contractor’s Board of Directors’ members, if applicable; or

(6) is a partner in the Contractor that is organized as a partnership.

Physician Incentive Plan means any compensation arrangement between the Contractor and a physician group that may directly or indirectly have the effect of reducing or limiting services furnished to Enrollees.

Poststabilization Care Services means Covered Services related to an Emergency Medical Condition that are provided after an Enrollee is stabilized in order to maintain the stabilized condition, or to improve or resolve the Enrollee’s condition.

Potential Enrollee means a Medicaid Member who is subject to mandatory enrollment or may voluntarily elect to enroll in a given Managed Care Program but is not yet an Enrollee of a specific PMHP.

Effective 7/1/2025

Prepaid Ambulatory Health Plan (PAHP) means an entity that provides medical services to Enrollees under contract with the Department and on the basis of prepaid Capitation Payments, or other payment arrangements that do not use State Plan payment rates; does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its Enrollees; and does not have a Comprehensive Risk Contract.

Prepaid Inpatient Health Plan (PIHP) means an entity that:

(1) provides medical services to Enrollees under contract with the Department, and on the basis of prepaid Capitation Payments, or other payment arrangements that do not use State Plan payment rates;

(2) provides, arranges for, or otherwise has responsibility for the provision of inpatient hospital or institutional services for its Enrollees; and

(3) does not have a Comprehensive Risk Contract.

Prepaid Mental Health Plan (PMHP) means a managed care plan that contracts with the Department to provide to its Enrollees mental health and substance use disorder services, or in one designated area of the State, mental health services only.

Primary Care Case Management (PCCM) means a system under which a PCCM contracts with the Department to furnish case management services (which include the location, coordination and monitoring of primary health care services) to Medicaid members.

Provider means a Network Provider or a Non-Network Provider.

Provider Preventable Condition means a condition that meets the definition of a HAC or Other Provider Preventable Condition.

Quality Assessment and Performance Improvement Program (QAPI Program or QAPIP) means the Contractor’s plan to establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its Enrollees in accordance with 42 CFR § 438.330.

Rate Cell means a set of mutually exclusive categories of Enrollees that is defined by one or more characteristics for the purpose of determining the Capitation Rate

Effective 7/1/2025 and making a Capitation Payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each Enrollee is categorized in one of the Rate Cells for each unique set of mutually exclusive benefits under the Contract.

Rating Period means a period of 12 months selected by the Department for which the actuarially sound Capitation Rates are developed and documented in the rate certification submitted to CMS as required by 42 CFR § 438.7(a).

Readily Accessible means electronic information and services that comply with modern accessibility standards such as section 508 guidelines, section 504 of the Rehabilitation Act, and W3C’s Web Content Accessibility Guidelines (WCAG) 2.0 AA and successor versions.

Recovery Period means the period of time the Contractor is allowed to recover any Overpayments on adjudicated Claims related to Fraud, Waste, or Abuse, ending 12 months from the Date of Discovery, or longer if the Contractor is actively collecting the Overpayment from the Provider.

Restriction Program means the program required by 42 CFR §§ 431.54(e) and

456.3 that provides safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments.

Risk Contract means a contract under which the contractor assumes risk for the cost of the services covered under the contract; and incurs loss if the cost of furnishing the services exceeds the payments under the contract.

Risk Corridor means a risk sharing mechanism in which the Department and the Contractor may share in profits and losses under the Contract outside of a predetermined threshold amount.

Serious Emotional Disturbance (SED) means a diagnosable mental, behavioral, or emotional disorder that significantly limits a child's ability to function in their family, school, or community.

Serious Mental Illness (SMI) means a mental, behavioral or emotional disorder resulting in serious functional impairment, which substantially interferes with or

Effective 7/1/2025 limits one or more major life activities. SMI applies to individuals who are 18 years of age or older.

Service Area means the counties enumerated in Article 1.3 of this attachment.

Service Authorization means a process through which a request for provisional approval of coverage is submitted to the Contractor or the Department for review.

Service Authorization Request means a Provider’s or Enrollee’s request to the Contractor for the provision of a service.

State Fair Hearing means the process set forth in subpart E of part 431 of CFR Title 42.

State Fiscal Year (SFY) means 12 calendar months commencing on July 1 and ending on June 30 following, or the 12-month period for which the State budgets funds.

State Directed Payment means a contract arrangement that directs the Contractor's expenditures under 42 CFR § 438.6(c).

State Health Care Program means:

(1) a state plan approved under Title XIX of the Social Security Act;

(2) any program receiving funds under Title V of the Social Security Act or from an allotment to a state under such title;

(3) any program receiving funds under Title XX of the Social Security Act or from an allotment to a state under such title; or

(4) a state child health plan approved under Title XXI of the Social Security Act.

State Match means the current percentage of the State’s share of Medicaid expenditures as defined under 42 CFR § 433.10.

State Plan means the Utah State Plan for organization and operation of the Medicaid program as defined pursuant to Section 1902 of the Social Security Act (42 USC 1396a).

Effective 7/1/2025

Subcontract means any written agreement between the Contractor and another party to fulfill the requirements of this Contract. Such term does not include insurance purchased by the Contractor to limit its loss with respect to an individual Enrollee.

Subcontractor means an individual or entity that has a contract with the Contractor that relates directly or indirectly to the performance of the Contractor’s obligations under this Contract. A Network Provider is not a Subcontractor by virtue of the Network Provider’s agreement with the Contractor. This definition of Subcontractor applies to attachments B, C, D, and E of this Contract unless otherwise specified.

Suspended means a Provider who has been Convicted of a program-related offense in a federal, state, or local court, and therefore, their items and services will not be reimbursed under Medicaid.

System for Award Management (SAM) means the official U.S. Government system, accessible to all, that consolidates Central Contractor Administration and Excluded Parties List System and other contractor databases. The purpose of SAM is to provide a single comprehensive list of individuals and firms Excluded by federal government agencies from receiving federal contracts or federal-approved subcontracts and from certain types of federal financial and non-financial assistance and benefits.

Teletypewriter Telecommunication Device/Telecommunication Devices for the Deaf (TTY/TDD) means any type of text-based telecommunications equipment used by a person who does not have enough functional hearing to understand speech, even with amplification.

Third Party means, but is not limited to, an individual, institution, corporation, public or private agency, trust, estate, insurance carrier, employee welfare benefit plan, health maintenance organization, health service organization, preferred provider organization, and governmental programs, that may be obligated to pay all or part of the expenditures for Covered Services.

Third Party Liability (TPL) means a Third Party’s obligation to pay all or part of the expenditures for Covered Services furnished under this Contract.

Effective 7/1/2025

Utah Medicaid Integrated Care (UMIC) Plan means a Utah MCO that contracts with the Department to provide medical and behavioral health (i.e., mental health and substance use disorder) services to its Enrollees.

Waste means overutilization of resources or inappropriate payment.

Article 3: Marketing and Enrollment

3.1 Marketing Activities

3.1.1 Marketing, Generally

(A) The Contractor, its employees, Network Providers, agents, or Subcontractors shall not conduct direct or indirect Marketing of the PMHP.

(B) The Contractor shall not market to or otherwise attempt to influence the Department’s Health Plan Representatives or local Health Department staff to encourage Enrollees or Potential Enrollees to enroll with the Contractor.

3.1.2 Prohibited Marketing Activities

The Contractor, its employees, Network Providers, agents, or Subcontractors are prohibited from:

(1) directly or indirectly, engaging in door-to-door, telephone, email, texting, or other Cold-Call Marketing activities;

(2) influencing a Potential Enrollee’s enrollment in conjunction with the sale or offering of any private insurance; and

(3) distributing any materials that include statements that will be considered inaccurate, false, or misleading. Such statements can include that the Potential Enrollee must enroll with the Contractor in order to obtain or not to lose benefits; or that the Contractor has been endorsed by CMS, the federal or State government, or similar entity.

Effective 7/1/2025

3.2 Contractor Marketing Responsibilities

3.2.1 Policies and Procedures

The Contractor shall maintain written policies and procedures related to Marketing that ensure compliance with the requirements described in Article 3 of this attachment.

3.2.2 Department Approval

All Marketing Materials must be reviewed and have the approval of the Department prior to distribution. The Contractor understands and agrees that when submitting any Marketing Materials to the Department for review, the Department is required to consult with the Medical Care Advisory Committee established under 42 CFR §

431.12 or an advisory committee with similar membership. Consultation with the Medical Care Advisory Committee may occur only after the Department approves the Marketing Material(s) for use by the Contractor.

3.2.3 Specify Methods

The Contractor shall specify the methods by which it assures the Department that Marketing, including plans and materials, is accurate and does not mislead, confuse, or defraud Potential Enrollees or the Department.

3.2.4 Distribution of Marketing Materials

The Contractor shall distribute Marketing Materials in the entire Service Area the Contractor serves.

3.2.5 Marketing Activities Prohibited

The Department has determined that no Marketing activities specifically directed at Potential Enrollees will be allowed under this Contract.

Effective 7/1/2025

3.3 Enrollment Process

3.3.1 Enrollment by the Department

The Department shall determine which Medicaid Eligible Individuals are to be enrolled with the Contractor.

Enrollees made eligible for a retroactive period prior to the current month are not eligible for Contractor enrollment during the retroactive period.

3.3.2 Period of Enrollment

(A) An Enrollee shall be considered enrolled with the Contractor during the months in which the Contractor receives a Capitation Payment from the Department.

(B) The Contractor shall assume that an Enrollee continues to be enrolled until the Department notifies the Contractor that the Enrollee is no longer enrolled.

The Contractor shall be responsible for verifying enrollment using the most current information available from the Department.

3.3.3 Prohibition Against Conditions on Enrollment

(A) The Contractor shall accept eligible Enrollees in the order in which they apply without restrictions (unless such restriction is authorized by CMS), up to the limits set under the Contract.

(B) The Parties may not pre-screen or select Potential Enrollees on the basis of pre-existing health problems.

(C) The Contractor shall not discriminate against Enrollees or Potential Enrollees on the bases defined in Section 1557 of the Affordable Care Act and 42 CFR § 438.3(d)(4) and shall not use any policy or practice that has the effect of discriminating on these bases.

(D) The Contractor shall not discriminate against Enrollees or against Potential Enrollees on the basis of health status or the need for health services.

Effective 7/1/2025

3.3.4 Enrollment Process

The Department may, at any time, revise the enrollment procedures. The Department shall advise the Contractor of the anticipated changes in advance whenever possible. The Contractor shall have the opportunity to make comments and provide input on the changes. The Contractor shall be bound by the changes in enrollment procedures.

3.4 Eligibility Transmission

3.4.1 Eligibility Transmission, Generally

(A) The Department shall provide to the Contractor an Eligibility Transmission which is an electronic file that includes data on individuals the Department certifies as being Medicaid-eligible and who have been enrolled in the Contractor’s PMHP. The Eligibility Transmission will include new Enrollees, reinstated Enrollees, retroactive Enrollees, terminated Enrollees and Enrollees whose eligibility information results in a change to a critical field.

(B) The Eligibility Transmission will be in accordance with the Utah Health Information Network (UHIN) standard. The Contractor shall have the ability to receive and process the Eligibility Transmission.

(C) Critical fields found in the Eligibility Transmission shall include:

(1) Enrollee's case number;

(2) case name;

(3) eREP identification number;

(4) name;

(5) date of birth;

(6) date of death;

(7) Social Security number;

(8) gender;

(9) prevalent language;

Effective 7/1/2025

(10) race;

(11) Capitation Rate Cell;

(12) pregnancy indicator;

(13) copayment/coinsurance indicators;

(14) eligibility start date;

(15) TPL coverage;

(16) county;

(17) address;

(18) phone number; and

(19) if applicable, the Enrollee’s Provider under the Restriction Program.

(D) The appearance of an individual’s name on the Eligibility Transmission, other than a deleted Enrollee, shall be evidence to the Contractor that the Department has determined that the individual is enrolled with the Contractor and qualifies for Medical Assistance under Title XIX of the Social Security Act.

(E) In addition to the monthly Eligibility Transmissions, the Department shall send daily Eligibility Transmissions to report changes to the Contractor.

3.4.2 Eligibility Transmission, Specific Types of Enrollees

For purposes of the Eligibility Transmission the following designations apply:

(1) New Enrollees shall be enrolled with the Contractor until they have been terminated from the Contractor’s PMHP. New Enrollees will not appear on future Eligibility Transmissions unless there is a change in a critical field.

(2) Reinstated Enrollees are individuals who were enrolled for the previous month and also terminated at the end of the previous month. These Enrollees are eligible starting at the beginning of the current month.

(3) Terminated Enrollees are individuals who are no longer eligible for Medicaid, were disenrolled from the Contractor, or had their Capitation Payment retracted.

Effective 7/1/2025

3.4.3 Eligibility File, Contractor Responsibilities

(A) The Contractor shall be responsible for ensuring that it is using the most recent Eligibility Transmission to determine eligibility and when processing Claims.

(B) The Contractor shall follow the policies and procedures found in the Department’s 834 Benefit and Enrollment Companion Guide, the HIPAA X12 Benefit Enrollment and Maintenance (834) Implementation Guide, and any amendments to these documents. The Department shall provide any additional instruction in writing to the Contractor. Whenever possible, the Department shall give at least 30 calendar days advance notice of any changes.

3.5 Enrollee Information

3.5.1 Enrollee Information, Generally

(A) The Contractor shall write all Enrollee and Potential Enrollee informational, instructional, and educational materials, in a manner and format that may be easily understood and is Readily Accessible by such Enrollees and Potential Enrollees and as close to the sixth grade reading level as possible. However due to complexity of the topics, the Contractor shall not be held to this reading level as long as the material is easily understood.

(B) The Enrollee information required under Article 3.5 of this attachment may not be provided electronically unless:

(1) it is in a format that is Readily Accessible;

(2) the information is placed on a location in the Contractor’s website that is prominent and Readily Accessible;

(3) the information is in an electronic form which can be electronically retained and printed;

(4) the information is consistent with content and language requirements;

and

Effective 7/1/2025

(5) the Contractor notifies the Enrollee that the information is available in paper form without charge upon request and provides it upon request within five business days.

(C) The Contractor shall have mechanisms in place to help Enrollees and Potential Enrollees understand the requirements and benefits of their plan.

(D) The Contractor shall make auxiliary aids and services available upon request of the Potential Enrollee or Enrollee at no cost, and in a manner that takes into consideration the special needs of Potential Enrollees or Enrollees with disabilities or limited English proficiency.

(E) The Contractor shall make interpretation services free of charge to each Enrollee, including oral interpretation and the use of auxiliary aids such as TTY/TDD and American Sign Language (ASL).

(F) The Contractor shall notify its Enrollees that:

(1) oral interpretation is available for any language, and how to access those services;

(2) written translation is available in prevalent languages, and how to access those services; and

(3) auxiliary aids and services are available upon request at no cost for Enrollees with disabilities, and how to access those services.

(G) The Contractor shall provide adult Enrollees with written information on Advance Directives policies and include a description of applicable State law. The information on Advance Directives provided to adult Enrollees must reflect changes in State law as soon as possible, but no later than 90 calendar days after the effective date of the change.

(H) The Contractor shall use the Department-developed definition for the following terms:

(1) Appeal;

(2) copayment;

(3) durable medical equipment;

Effective 7/1/2025

(4) Emergency medical Condition;

(5) emergency medical transportation;

(6) emergency room care;

(7) Emergency Services;

(8) excluded services;

(9) Grievance;

(10) habilitation services and devices;

(11) health insurance;

(12) home health care;

(13) hospice services;

(14) hospitalization;

(15) hospital outpatient care;

(16) Medically Necessary;

(17) network;

(18) Network Provider;

(19) non-participating provider;

(20) participating provider;

(21) PCP;

(22) physician services;

(23) plan;

(24) preauthorization;

(25) premium;

(26) prescription drug coverage;

(27) prescription drugs;

Effective 7/1/2025

(28) Primary Care Physician;

(29) Provider;

(30) rehabilitation services and devices;

(31) skilled nursing care;

(32) specialist; and

(33) urgent care.

(I) The Department shall provide model Enrollee notices to the Contractor. The Contractor shall ensure all content in the Department's model notices is addressed in the Contractor's notices.

3.5.2 Determining Prevalent Language

The Contractor shall use Eligibility Transmissions to determine prevalent non- English languages. A language is prevalent when it is spoken by five percent or more of the Contractor’s enrolled population.

3.5.3 All Written Materials

(A) The Contractor shall provide all written materials for Potential Enrollees and Enrollees in an easily understood language and format, and in a font size no smaller than 12 point.

(B) The Contractor shall provide all written materials for Potential Enrollees and Enrollees in alternative formats upon request and at no cost, and in an appropriate manner that takes into consideration the special needs of Potential Enrollees or Enrollees with disabilities or limited English proficiency.

3.5.4 Written Materials Critical to Obtaining Services

(A) The Contractor shall make its written materials that are critical to obtaining services, including, at a minimum, provider directories, Enrollee handbooks, Appeal and Grievance notices, and denial and termination notices, available in the prevalent…