503Anthem21HCC AM07 51705.pdf

AMENDMENT #7

CONTRACT #0000000000000000000051705

This is an amendment to the Contract (the "Contract") entered into by and between the Indiana Family and Social Services Administration (FSSA) (the "State") and Anthem Insurance

Companies Inc. (the "Contractor") approved by the last State signatory on April 16, 2021.

In consideration of the mutual undertakings and covenants hereinafter set forth, the parties agree as follows:

The Contract for providing risk-based managed care services to Medicaid beneficiaries enrolled in the State of Indiana’s Hoosier Care Connect program is hereby amended to update Exhibits

1.F, 2.F, 3.C, 5.E, and 6.C. Unless otherwise noted, and subject to specific provisions within each

Exhibit, this amendment shall be effective January 1, 2026.

Exhibit 1.F, which outlines the Scope of Work, is hereby superseded and replaced by Exhibit

1.G, which is attached hereto and incorporated herein.

Exhibit 2.F, which outlines the Contract Compliance and Pay for Outcomes, is hereby superseded and replaced by Exhibit 2.G, which is attached hereto and incorporated herein.

Exhibit 3.C, which outlines the Program Description and Covered Benefits, is here by superseded and replaced by Exhibit 3.D, which is attached hereto and incorporated herein.

Exhibit 5.E, which outlines the State’s Capitation Rates, is hereby superseded and replaced by

Exhibit 5.F, which is attached hereto and incorporated herein.

Exhibit 6.C, which outlines the Contract Definitions, is hereby superseded and replaced by

Exhibit 6.D, which is attached hereto and incorporated herein.

Funding in the amount of $2,474,012,869.77 is being added to the total contract amount. Total remuneration under the Contract is not to exceed $7,190,550,783.61.

The Contract term is extended two (2) years, three (3) months. The Contract will terminate on

June 30, 2028.

Additionally, Clause 18. Employment Eligibility Verification is hereby superseded and replaced by the following:

18. Employment Eligibility Verification.

As a condition precedent to entering this contract, and as required by IC § 22-5-1.7 and

Executive Order 25-29, the Contractor swears or affirms under the penalties of perjury that the Contractor has not knowingly employed, and will not knowingly employ, an unauthorized alien. The Contractor further affirms that:

A. The Contractor has enrolled in, and verified the work eligibility status of all his/her/its employees through, the E-Verify program as defined in IC § 22-5-1.7-3.

The Contractor is not required to participate should the E-Verify program cease to exist. Additionally, the Contractor is not required to participate if the Contractor is self-employed and does not employ any employees.

Docusign Envelope ID: 30881BFA-859C-4CAA-9E60-266B57DB5A1E

B. The Contractor has not knowingly employed or contracted with, and shall not knowingly employ or contract with, an unauthorized alien. The Contractor has not retained, and shall not retain, an employee, and has not contracted and shall not contract with a person, that the Contractor subsequently learned or learns is an unauthorized alien.

C. The Contractor has required and shall require his/her/its subcontractors, who perform work under this Contract, to certify to the Contractor that the subcontractor does not knowingly employ or contract with an unauthorized alien and that the subcontractor has enrolled and is participating in the E-Verify program. The Contractor agrees to maintain this certification throughout the duration of the term of a contract with a subcontractor and to provide any and all such certifications to the State promptly upon request.

The State may terminate this agreement for default if the Contractor fails to cure a breach of this provision no later than thirty (30) days after being notified by the State.

Additionally, Clause 27. “Information Technology Enterprise Architecture Requirements is hereby superseded and replaced by the following:

27. Information Technology Enterprise Architecture Requirements.

If this Contract involves information technology -related products or services, the

Contractor agrees that all such products or services are compatible with any of the technology standards found at https://www.in.gov/iot/policies-procedures-and-standards/ that are applicable, including the assistive technology standard. The State may terminate this Contract for default if the terms of this paragraph are breached.

Additionally, subclause A of Clause 28. Insurance is hereby superseded and replaced by the following:

28. Insurance.

A. The Contractor and its subcontractors (if any) shall secure and keep in force during the term of this Contract the following insurance coverages (if applicable) covering the

Contractor for any and all claims of any nature which may in any manner arise out of or result from Contractor's performance under this Contract:

1. Commercial general liability, including contractual coverage, and products or completed operations coverage (if applicable), with minimum liability limits not less than $700,000 per person and $5,000,000 per occurrence unless additional coverage is required by the State. The

State is to be named as an additional insured on a primary, non-contributory basis for any liability arising directly or indirectly under or in connection with this Contract.

2. Automobile liability for owned, non-owned and hired autos with minimum liability limits not less than $700,000 per person and $5,000,000 per occurrence. The State is to be named as an additional insured on a primary, non-contributory basis.

3. Errors and Omissions liability with minimum liability limits of $1,000,000 per claim and in the aggregate. Coverage for the benefit of the State shall continue for a period of two (2) years after the date of service provided under this Contract.

https://www.in.gov/iot/policies-procedures-and-standards/

4. Fiduciary liability if the Contractor is responsible for the management and oversight of various employee benefit plans and programs such as pensions, profit-sharing and savings, among others with limits no less than $700,000 per cause of action and $5,000,000 in the aggregate.

5. Valuable Papers coverage, if applicable, with an Inland Marine Policy

Insurance with limits sufficient to pay for the re-creation and reconstruction of such records.

6. Surety or Fidelity Bond(s) if required by statute or by the agency.

7. Cyber Liability addressing risks associated with electronic transmissions, the internet, networks and informational assets, and having limits of no less than $700,000 per occurrence and $5,000,000 in the aggregate.

The Contractor shall provide proof of such insurance coverage by tendering to the undersigned State representative a certificate of insurance prior to the commencement of this Contract and proof of workers' compensation coverage meeting all statutory requirements of IC § 22-3-2. In addition, proof of an "all states endorsement" covering claims occurring outside the State is required if any of the services provided under this Contract involve work outside of Indiana. All insurance documents shall be sent electronically as pdf documents to insurancedocuments.fssa@fssa.in.gov.

Additionally, Clause 33 “Nondiscrimination” is hereby superseded and replaced by the following:

33. Nondiscrimination.

Pursuant to the Indiana Civil Rights Law, specifically IC § 22-9-1-10, and in keeping with the purposes of the federal Civil Rights Act of 1964, the Age Discrimination in Employment Act, and the Americans with Disabilities Act:

A. The Contractor covenants that it shall not discriminate against any employee or applicant for employment relating to this Contract with respect to the hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment, because of the employee's or applicant's race, color, national origin, religion, sex, age, disability, ancestry, status as a veteran, or any other characteristic protected by federal, state, or local law ("Protected Characteristics"). The Contractor certifies compliance with applicable federal laws, regulations, and executive orders prohibiting discrimination based on the Protected Characteristics in the provision of services. Breach of this subparagraph may be regarded as a material breach of this Contract, including for purposes of Indiana Code § 5-11-5.5-2, but nothing in this paragraph shall be construed to imply or establish an employment relationship between the State and any applicant or employee of the Contractor or any subcontractor.

B. Contractor covenants that it does not and shall not operate any programs or engage in any practices promoting Diversity, Equity, and Inclusion (DEI), or other similar goals, that violate Indiana or Federal Civil Rights Laws by treating a person differently on the basis of race or sex, such as by considering race or sex when making recruitment, hiring, disciplinary, promotion, or employment decisions; requiring employees to participate in training or educational programs that employ racial or sex stereotypes; or attempting to achieve racial or sex balancing in the Contractor's workforce. The Parties agree that a breach of this subparagraph is a material breach of this Contract, including for purposes of Indiana Code § 5-11-5.5-2, but nothing in this paragraph shall be construed to imply or mailto:insurancedocuments.fssa@fssa.in.gov establish an employment relationship between the State and any applicant or employee of the Contractor or any subcontractor.

Additionally, the Contractor’s Division of Supplier Diversity (“DSD”) ongoing obligations have been updated as detailed in the IDOA DSD Letter of Determination, dated July 8, 2025, and are as follows:

A. Clause 26. Indiana Veteran Owned Small Business Enterprise Compliance remains unchanged with a 0% change in overall commitment obligations. Therefore, Clause 26 remains as follows:

Award of this Contract was based, in part, on the Indiana Veteran Owned Small Business Enterprise (“IVOSB”) participation plan, as detailed in the IVOSB Subcontractor Commitment

Form, commonly referred to as “Attachment A-1” in the procurement documentation and incorporated by reference herein. Therefore, any changes to this information during the Contract term must be approved by IDOA’s IVOSB Division (“IVOSB Division”) and may require an amendment. It is the State’s expectation that the Contractor will meet the subcontractor commitments during the Contract term. The following certified IVOSB subcontrac tor(s) will be participating in this Contract:

IVB

PHONE/

EMAIL

COMPANY

NAME

SCOPE OF PRODUCTS and/or

SERVICES

UTILIZATION

DATE

PERCENT

IVOSB

(317) 370-markshepl er@startat onepoint.c om

Printer Zink, Inc.

d/b/a One Point

(One Point)

Support for printing needs, including member handbooks and other informative collateral materials for members.

4/1/2021–

3/31/2027 0.50%

IVOSB

(260) 450-chris.straw

@teamqua lityservices

.com

Team Quality

Services

Provide independent external operational audits for certain subcontractors.

4/1/2021–

3/31/2027 0.25%

IVOSB

(410) 533-vespa@ve spagroup.c om

Vespa Group

Provide staff augmentation for technical and other operations teams.

4/1/2021–

3/31/2027 2.51%

A copy of each subcontractor agreement must be submitted to the IVOSB Division within thirty

(30) days of the effective date of this Contract. The subcontractor agreements may be uploaded into Pay Audit (Indiana’s subcontractor payment auditing system), emailed to IndianaVeteransPreference@idoa. IN.gov, or mailed to IDOA, 402 W. Washington Street, Room

W-478, Indianapolis, IN 46204. Failure to provide a copy of any subcontractor agreement may be deemed a violation of the rules governing IVOSB procurement and may result in sanctions allowable under 25 IAC 9-5-2. Requests for changes must be submitted to

IndianaVeteransPreference@idoa. IN.gov for review and approval before changing the participation plan submitted in connection with this Contract.

The Contractor shall report payments made to certi fied IVOSB subcontractors under this Contract on a monthly basis using Pay Audit. The Contractor shall notify subcontractors that they must confirm payments received from the Contractor in Pay Audit. The Pay Audit system can be accessed on the IDOA webpage at: www.in.gov/idoa/mwbe/payaudit.htm. The Contractor may also be required to report IVOSB certified subcontractor payments directly to the IVOSB Division, as reasonably requested and in the format required by the IVOSB Division.

The Contractor’s failure to comply with the provisions in this clause may be considered a material breach of the Contract.

A. Clause 32. Minority and Women’s Business Enterprises Compliance remains unchanged with a 0% change in overall commitment obligations. Therefore Clause 32 remains as follows:

Award of this Contract was based, in part, on the Minority and/or Women’s Business Enterprise (“MBE” and/or “WBE”) participation plan as detailed in the Minority and Women’s Business Enterprises Subcontractor Commitment Form, commonly referred to as “Attac hment A” in the procurement documentation and incorporated by reference herein. Therefore, any changes to this information during the Contract term must be approved by MWBE Compliance and may require an amendment. It is the State’s expectation that the Contractor will meet the subcontractor commitments during the Contract term.

The following MBE/WBE Division (“Division”) certified MBE and/or WBE subcontractors will be participating in this Contract:

MBE/

WBE

PHONE/

EMAIL

COMPANY

NAME

SCOPE OF PRODUCTS

and/or SERVICES

UTILIZATIO

N DATE PERCENT

WBE

(317) 209-kg_cabell o@cabell oassociat es.com

Cabello

Associates, Inc.

Provide assistance with marketing strategy, research, and implementation, creative, development and production services, advertising campaign implementation, media plan/buy, and incentive campaign management/fulfillment.

4/1/2021-

3/31/2027 0.30

WBE

(317) 514-emily@co nsultmg.c om

MG

Consulting, Inc.

Provide consulting, assistance with implementing Quality

Improvement (QI) program structure and activities, NCQA accreditation preparation, HEDIS® data collection, and Quality Improvement (QI) reporting and analytics.

4/1/2021-

3/31/2027 1.01

Docusign Envelope ID: 30881BFA-859C-4CAA-9E60-266B57DB5A1E mailto:kg_cabello@cabelloassociates.com mailto:kg_cabello@cabelloassociates.com mailto:kg_cabello@cabelloassociates.com mailto:kg_cabello@cabelloassociates.com mailto:emily@consultmg.com mailto:emily@consultmg.com mailto:emily@consultmg.com

MBE

(317) 488-william@p me-indy.com

Professional

Management

Enterprises, Inc.

Provide Non-Emergency

Transportation (NEMT) broker services, and staff augmentation services for

Indiana Medicaid’s Outbound

Call Center and staff augmentation services for direct member outreach programs.

4/1/2021-

3/31/2027 11.06

WBE

(317)

218-0650 bdragoo@ repucare.

com

RepuCare, Inc.

Provide staff augmentation support for HEDIS® data collection.

4/1/2021-

3/31/2027 3.50

WBE

(812)

369-0385 robaileyc onsulting @gmail.c om

Robailey

Consulting, LLC

Provide Indiana-specific expertise in operations, claims, and utilization management.

4/1/2021-

3/31/2027 1.50

WBE

(317) 695-tkrigger@ onebridg e.tech

Smart IT

Staffing, Inc.

d/b/a

Onebridge

Provide technical staff augmentation support.

4/1/2021-

5/24/2021 .50

WBE

(317) 610-yrobles@t heculturali nk.com

CulturaLink Face to face translation services for members.

5/25/2021-

3/31/2027 .50

WBE

(317) 469-

Greta.clin e@thatsg oodHR.co m

That’s Good

HR

Provide augmentation for clinical and other operations teams.

4/1/2021-

11/15/2021 2.00

WBE

(317) 541-dbahnse n@pme-indy.com

BKG

Enterprises

Provide program management support and augmentation for clinical and other operations teams.

11/16/2021-

3/31/2027 2.00

WBE

(219)

362-4411 phil.wood s@vision sprr.com

Vision

Financial

Services

Provide outreach to members, assisting them in redetermination to make sure they do not lose eligibility and maintain coverage.

4/1/2021-

3/31/2027 0.75

Docusign Envelope ID: 30881BFA-859C-4CAA-9E60-266B57DB5A1E mailto:william@pme-indy.com mailto:william@pme-indy.com mailto:william@pme-indy.com mailto:bdragoo@repucare.com mailto:bdragoo@repucare.com mailto:bdragoo@repucare.com mailto:bdragoo@repucare.com mailto:robaileyconsulting@gmail.com mailto:robaileyconsulting@gmail.com mailto:robaileyconsulting@gmail.com mailto:robaileyconsulting@gmail.com mailto:tkrigger@onebridge.tech mailto:tkrigger@onebridge.tech mailto:tkrigger@onebridge.tech mailto:yrobles@theculturalink.com mailto:yrobles@theculturalink.com mailto:yrobles@theculturalink.com mailto:yrobles@theculturalink.com mailto:Greta.cline@thatsgoodHR.com mailto:Greta.cline@thatsgoodHR.com mailto:Greta.cline@thatsgoodHR.com mailto:Greta.cline@thatsgoodHR.com mailto:dbahnsen@pme-indy.com mailto:dbahnsen@pme-indy.com mailto:dbahnsen@pme-indy.com mailto:phil.woods@vision mailto:phil.woods@vision mailto:phil.woods@visionsprr.com

A copy of each subcontractor agreement must be submitted to the Division within thirty (30) days of the effective date of this Contract. The subcontractor agreements may be uploaded into Pay Audit (Indiana’s subcontractor payment auditing system), emailed to MWBECompliance@idoa.IN.gov, or mailed to MWBE Compliance, 402 W. Washington Street, Indianapolis IN 46204. Failure to provide a copy of any subcontractor agreement may be deemed a violation of the rules governing MBE/WBE procurement and may result in sanctions allowable under 25 IAC 5-7-8. Requests for changes must be submitted to MWBECompliance@idoa.IN.gov for review and approval before changing the participation plan submitted in connection with this Contract.

The Contractor shall report payments made to Division certified subcontractors under this Contract on a monthly basis using Pay Audit. The Contractor shall notify subcontractors that they must confirm payments received from the Contractor in Pay Audit. The Pay Audit system can be accessed on the IDOA webpage at: www.in.gov/idoa/mwbe/payaudit.htm. The Contractor may also be required to report Division certi fied subcontractor payments directly to the Division, as reasonably requested and in the format required by the Division.

The Contractor’s failure to comply with the provisions in this clause may be considered a material breach of the Contract.

Additionally, Clause 34 “Notice to Parties” is hereby replaced and superseded by the following:

34. Notice to Parties.

Whenever any notice, statement or other communication is required under this Contract, it will be sent by E-mail or first class U.S. mail service to the following addresses, unless otherwise specifically advised.

A. Notices to the State shall be sent to:

Mitchell Roob, Secretary of the Family and Social Services Administration and

Director of the Office of Medicaid Policy and Planning

Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning

402 W. Washington Street, Room W461

Indianapolis, IN 46204

Email: mitch.roob@fssa.IN.gov

B. Notices to the Contractor shall be sent to:

K. Lynn Scott, Medicaid Plan President and CEO

Anthem Insurance Companies, Inc., dba Anthem Blue Cross and Blue Shield

220 Virginia Avenue

Indianapolis, Indiana 46204

Email: KLynn.Scott@anthem.com

As required by IC § 4-13-2-14.8, payments to the Contractor shall be made via electronic funds transfer in accordance with instructions filed by the Contractor with the Indiana Auditor of State.

All other matters previously agreed to and set forth in the original Contract and Amendments #1-6 and not affected by this Amendment shall remain in full force and effect.

Docusign Envelope ID: 30881BFA-859C-4CAA-9E60-266B57DB5A1E http://www.in.gov/idoa/mwbe/payaudit.htm mailto:cora.steinmetz@fssa.in.gov mailto:Lynn.Scott1@anthem.com

Non-Collusion and Acceptance

The undersigned attests, subject to the penalties for perjury, that the undersigned is the

Contractor, or that the undersigned is the properly authorized representative, agent, member or officer of the Contractor. Further, to the undersigned's knowledge, neither the undersigned nor any other member, employee, representative, agent or officer of the Contractor, directly or indirectly, has entered into or been offered any sum of money or other consideration for the execution of this Contract other than that which appears upon the face hereof. Furthermore, if the undersigned has knowledge that a state officer, employee, or special state appointee, as those terms are defined in IC § 4-2-6-1, has a financial interest in the Contract, the Contractor attests to compliance with the disclosure requirements in IC § 4-2-6-10.5.

Agreement to Use Electronic Signatures

I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of

Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: https://secure.in.gov/apps/idoa/contractsearch/

In Witness Whereof, the Contractor and the State have, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective s ignatures dated below agree to the terms thereof.

ANTHEM INSURANCE COMPANIES INC Indiana Family & Social Services Administration

Office of Medicaid Policy and Planning

By:\s1\ By:\s2\

Title:\t1\ Title:\t2\

Date:\d1\ Date:\d2\

Electronically Approved by:

Department of Administration

By: (for) Brandon Clifton, Commissioner

Electronically Approved by:

State Budget Agency

Chad Ranney, State Budget Director

Electronically Approved as to Form and Legality by:

Office of the Attorney General

Theodore E Rokita, Attorney General

12/29/2025 | 14:47 EST

President, Indiana Medicaid Deputy Secretary

12/29/2025 | 18:13 PST

https://secure.in.gov/apps/idoa/contractsearch/

EXHIBIT 1G

SCOPE OF WORK

Table of Contents

1.0 Background

2.0 Administrative Requirements

2.1 State Licensure

2.2 National Committee for Quality Assurance (NCQA) Accreditation

2.3 Subcontracts

2.4 Financial Stability

2.4.1 Solvency

2.4.2 Insolvency and Receivership

2.4.3 Reinsurance

2.4.4 Performance Bond Requirements

2.4.5 Financial Accounting Requirements

2.4.6 Insurance Requirements

2.5 Maintenance of Records

2.6 Disclosures

2.6.1 Definition of a Party in Interest

2.6.2 Types of Transactions Which Must Be Disclosed

2.7 Debarred Individuals

2.8 Medical Loss Ratio (MLR)

2.9 Reserved

2.10 Administrative and Organizational Structure

2.10.1 Staffing

2.10.2 Key Staff

2.10.3 Other Required Staff Positions

2.10.4 Suggested Staff Positions

2.10.5 Staff Training and Qualifications

2.11 FSSA Meeting Requirements

2.12 Maintenance of Written Policies and Procedures

2.13 Participation in Readiness Review

2.14 Confidentiality of Member Medical Records and Other Information

2.15 Material Change to Operations

2.16 Response to State Inquiries & Requests for Information

2.17 Dissemination of Information

2.18 FSSA Ongoing Monitoring

2.19 Future Program Guidance

2.20 Capitation Related to a Vacated Program

2.21 Compliance with Applicable Laws, Rules and Regulations

3.0 Covered Benefits

3.1 Self-Referral Services

3.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

3.3 Emergency Services

3.3.1 Non-Emergency Room Services

3.3.2 Post-Stabilization Services

3.4 Inpatient Services

3.5 Care Conference Coverage

3.6 Medication Therapy Management Services

3.6.1 Goals of the MTM Program

3.6.2 General Requirements

3.6.3 Target Members

3.6.4 Reporting

3.7 Diabetes Supplies Coverage

3.8 Drug Coverage

3.8.1 Drug Rebates

3.8.2 SUPDL and Formulary Requirements

3.8.3 DUR Board and MHQAC Reporting Requirements

3.8.4 Dispensing and Monitoring Requirements

3.8.5 E-Prescribing

3.8.6 Carve-Out of Select Drugs

3.8.7 340B

3.8.8 Pharmacy Continuity of Care

3.8.9 SUPPORT Act Compliance

3.9 Smoking Cessation and Tobacco Dependence Treatment

3.10 Behavioral Health Services

3.10.1 Identification of Behavioral Health Care Needs

3.10.2 Behavioral Health Care Coordination

3.10.3 Behavioral Health Continuity of Care

3.10.4 Institution for Mental Disease (IMD)

3.11 Dental Services

3.12 Inpatient Hospitalization Notification

3.13 Carved-Out Services

3.13.1 Medicaid Rehabilitation Option (MRO) Services

3.13.2 1915(i) State Plan Home and Community-Based Services

3.13.3 Individualized Family Services Plan (IFSP)

3.13.4 Individualized Education Plan (IEP) Services

3.13.5 Carved Out Drug Classes

3.14 Excluded Services

3.14.1 Long-Term Institutional Care

3.14.2 Psychiatric Treatment in a State Hospital

3.14.3 Psychiatric Residential Treatment Facility (PRTF) Services

3.14.4 Intermediate Care Facilities for Individuals with Intellectual Disabilities

3.14.5 Home and Community-Based Services (HCBS)

3.15 Continuity of Care

3.16 Out-of-Network Services

3.16.1 Directed Payment for Eligible Out-of-State Children’s Hospitals

3.17 Enhanced Services

3.18 Opioid Treatment Program (OTP)

3.19 Non-Emergency Medical Transportation Services

3.20 Residential Substance Use Disorder (SUD) Services

3.21 Hospice Services

4.0 Member Services

4.1 Marketing and Outreach

4.2 Member Enrollment and Contractor Selection

4.3 Enrollment and Practice Discrimination

4.4 Enrollment Packet

4.4.1 Provider Network Information

4.4.2 Member Handbook

4.4.3 Member ID Card

4.5 Member Disenrollment

4.6 Member-Contractor Communications

4.6.1 Member Services Helpline and 24 Hour Nurse Line

4.6.2 Electronic Communications

4.7 Member Information, Education and Outreach

4.7.1 Member and Stakeholder Education and Engagement

4.7.2 General Member Information Requirements

4.7.3 Additional Information Available Upon Request

4.7.4 Oral Interpretation Services

4.7.5 Health Equity

4.7.6 Advance Directive Information

4.7.7 Member Website

4.7.8 Preventive Care Information

4.7.9 Cost and Quality Information

4.7.10 Member Education

4.8 Member-Provider Communications

4.9 Member and Potential Member Communications Review and Approval

4.10 Member Rights

4.11 Redetermination Assistance

4.12 Member Inquiries, Grievances & Appeals

4.12.1 Contractor Grievance and Appeals Policies

4.12.2 Inquiry Processing Requirements

4.12.3 Grievance Processing Requirements

4.12.4 Appeals Processing Requirements

4.12.5 External Review by Independent Review Organization

4.12.6 State Fair Hearing Process

4.12.7 Continuation of Benefits Pending Appeal & Reinstatement of Benefits

4.12.8 Member Notices of Action & Grievance, Appeal and Fair Hearing Procedures

4.12.9 Recordkeeping Requirements of Grievance and Appeals

4.13 Member Cost-Sharing Limits

5.0 Care Coordination

5.1 Member Assessment

5.1.1 Initial Screening

5.1.2 Comprehensive Health Assessment

5.1.3 Identification and Assessment of Pregnant Women

5.2 Stratification & Level of Service

5.2.1 Disease Management Level of Service

5.2.2 Care Management Level of Service

5.2.3 Complex Case Management (Member Focus) Level of Service

5.2.4 Complex Case Management (Provider Focus) Level of Service

5.2.5 Right Choices Program Level of Service

5.3 Care Plan Development

5.3.1 Disease Management Care Plans

5.3.2 Care Management Care Plans

5.3.3 Complex Case Management Care Plans

5.3.4 RCP Care Plans

5.4 Reassessments

6.0 Provider Network Requirements

6.1 Network Development

6.1.1 Access to Culturally and Linguistically Competent Providers

6.2 Network Composition Requirements

6.2.1 Acute Care Hospital Facilities

6.2.2 Inpatient Psychiatric Facilities

6.2.3 Primary Medical Providers (PMP)

6.2.4 Specialist and Ancillary Providers

6.2.5 Non-Psychiatrist, Non-Substance Use Disorder (SUD) Behavioral Health Providers

6.2.6 SUD Providers

6.2.7 Dental Providers

6.2.8 County Health Departments

6.2.9 Urgent Care Clinics

6.2.10 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

6.2.11 Pharmacies

6.2.12 Other Providers

6.2.13 Physician Extenders

6.2.14 Indian Healthcare Providers

6.2.15 Non-Emergency Medical Transportation Providers

6.3 Provider Accessibility

6.4 Provider Enrollment and Disenrollment

6.5 Provider Agreements

6.6 Provider Credentialing

6.7 Medical Records

6.8 Provider Education and Outreach

6.8.1 Provider Communications Review and Approval

6.8.2 Provider Policy and Procedures Manual

6.8.3 Provider Newsletters

6.8.4 Provider Website

6.8.5 Provider Services Helpline

6.8.6 IHCP Roadshows and Seminars

6.8.7 Provider Welcome Letter

6.9 Payment for Health Care-Acquired Conditions and Provider-Preventable Conditions

6.10 Hospital Assessment Fee

6.11 Member Payment Liability

6.12 Physician Faculty Access to Care (PFAC) Program

6.13 State-directed Applied Behavioral Analysis (ABA) Reimbursement

7.0 Quality Assessment, Performance Improvement, and Utilization Management

7.1 Quality Assessment and Performance Improvement Program

7.1.1 Quality Assessment and Performance Improvement Committee

7.1.2 Quality Management and Improvement Work Plan Requirements

7.1.3 External Quality Review

7.2 Incentive Programs

7.2.1 Provider Incentive Programs

7.2.2 Member Incentive Programs

7.3 Utilization Management Program

7.3.1 Authorization of Services and Notices of Actions

7.3.2 Objection on Moral or Religious Grounds

7.3.3 Utilization Management Committee

7.4 Program Integrity

7.4.1 Program Integrity Plan

7.4.2 Program Integrity Operations

7.4.3 Program Integrity Reporting

7.4.4 Program Integrity Overpayment Recovery

7.4.5 Auditing Program Integrity Operations

7.5 Monitoring and Reporting Foster Children Psychotropic Medication Use

8.0 Information Technology (IT) Systems

8.1 Testing with the State

8.1.1 Master Test Plan

8.2 Business Contingency and Disaster Recovery Plans

8.3 Member Enrollment Data Exchange

8.4 Provider Network Data

8.5 Claims Processing

8.5.1 Claims Processing Capabilities

8.5.2 Compliance with State and Federal Claims Processing Regulations

8.5.3 Claims Payment Timelines

8.5.4 Rate Update Timeliness

8.5.5 Medicaid National Correct Coding Initiative (NCCI)

8.6 Encounter Data Submission

8.6.1 Definition and Uses of Encounter Data

8.6.2 Reporting Format and Batch Submission Schedule

8.6.3 Encounter Claims Quality

8.7 Third Party Liability (TPL) Issues

8.7.1 Coordination of Benefits

8.7.2 Collection and Reporting

8.7.3 Cost Avoidance

8.7.4 Retroactive Medicare Coverage

8.7.5 Cost Avoidance Exceptions

8.8 Health Information Technology and Interoperability

9.0 Performance Reporting and Incentives

9.1 Administrative and Financial Reports

9.2 Member Service Reports

9.3 Network Development Reports

9.4 Provider Service Reports

9.5 Quality Management Reports

9.6 Utilization and Authorization Reports

9.6.1 Prior Authorization Detail

9.7 Care Coordination Reports

9.8 Claims Reports

9.9 Health Outcomes and Clinical Reporting

9.10 CMS Reporting

9.11 Other Reporting

10.0 Failure to Perform/Non-compliance Remedies

11.0 Termination Provisions

11.1 Contract Terminations

11.1.1 Termination by the State for Contractor Default

11.1.2 Termination for Financial Instability

11.1.3 Termination for Failure to Disclose Records

11.1.4 Termination by the Contractor

11.2 Termination Procedures

11.3 Contractor Responsibilities upon Termination or Expiration of the Contract

11.4 Damages

11.5 Assignment of Terminating Contractor’s Membership and Responsibilities

11.6 Refunds of Advanced Payments

11.7 Termination Claims

This Scope of Work is part of a Contract to provide risk-based managed care services to Medicaid beneficiaries enrolled in the State of Indiana’s Hoosier Care Connect program. The

State shall contract on a statewide basis with managed care entities (MCEs) with a demonstrated capacity to actively manage and coordinate care for low income disabled populations. This includes specific experience and demonstrated success in operating care coordination programs for low income individuals with significant health needs. MCEs must meet all applicable requirements of Medicaid managed care organizations under Sections 1903(m) and 1932 of the Social Security Act, as well as the implementing regulations set forth in 42 CFR 438, and IC 12-

15 as may be amended.

1.0 Background

The Indiana Family and Social Services Administration (FSSA) through the Office of Medicaid Policy and Planning (OMPP) manages the Hoosier Care Connect program, which will serve approximately 90,000 Hoosiers. Hoosier Care Connect is a coordinated care program for

Indiana’s Medicaid enrollees with a disability who are not Medicare eligible and do not have an institutional level of care. The program also includes voluntary enrollment for wards, foster children, former foster children and children receiving adoption assistance.

Through the Hoosier Care Connect program, FSSA seeks to continue to improve the quality of care and health outcomes for members. This includes improved clinical and functional status, enhanced quality of life, improved member safety, enhanced member autonomy and adherence to treatment plans. In developing Hoosier Care Connect, FSSA seeks to achieve the following goals:

Improve quality outcomes and consistency of care across the delivery system;

Ensure enrollee choice, protections and access;

Coordinate care across the delivery system and care continuum; and

Provide flexible person-centered care.

2.0 Administrative Requirements

2.1 State Licensure

Prior to the Contract effective date, and as verified in the readiness review described in

Section 2.13, the Contractor must be an Indiana licensed accident or sickness insurer or an Indiana licensed health maintenance organization (HMO).

The Contractor and all subcontractors shall use clinicians licensed by Indiana and follow all requirements contained within the Contract (e.g., PA/UM criteria; claims processing;

encounter data submission; etc.), regardless of geographic location.

2.2 National Committee for Quality Assurance (NCQA) Accreditation

The Contractor must be accredited by the NCQA pursuant to IC 12-15-12-21. If not already NCQA accredited, the Contractor shall initiate the health plan accreditation process immediately following the Contract start date and must achieve accreditation prior to January 1, 2027, or one year from contract execution date, unless the Contractor requests an extension which is granted solely at FSSA’s discretion. When accreditation standards conflict with the standards set forth in the Contract or State law, the Contract or

State law prevails unless the accreditation standard is more stringent.

Per 42 CFR 438.332(b), the Contractor must authorize NCQA to provide the State with a copy of its most recent accreditation review including: its accreditation status, survey type, and level (as applicable); recommended actions or improvements, corrective action plans, and summaries of findings; and the expiration date of the accreditation.

2.3 Subcontracts

The term “subcontract(s)” includes contractual agreements between the Contractor and health care providers or other ancillary medical providers.

Per 42 CFR 438.2, a provider is defined as any individual, organization, or institution (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, ambulatory surgical centers, outpatient clinics etc.) that provides medical services to beneficiaries covered under this

Additionally, the term “subcontract(s)” includes contracts between the Contractor and another prepaid health plan, physician hospital organization, dental benefits manager, transportation broker or any entity that performs delegated activities related to the Contract and any administrative entities not involved in the actual delivery of medical care.

The Contractor shall maintain ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its Contract with the State, notwithstanding any relationship(s) with any subcontractor per 42 CFR 438.230(b)(1) and 42 CFR 438.3(k).

Subcontractor agreements do not terminate the legal responsibility of the Contractor to the State to ensure that all activities under the Contract are carried out. Prior to delegation, the Contractor shall evaluate the prospective subcontractor’s ability to perform the activities to be delegated. All subcontracts must be supported by a written agreement that specifies the activities and reporting responsibilities delegated to the subcontractor and provides for revoking delegation or imposing other sanctions if the subcontractor’s performance is inadequate. The Contractor shall also ensure all written subcontracts meet the requirements of 42 CFR 434.6 and shall incorporate by reference the applicable terms and conditions of the Contract. According to IC 12-15-30-5, subcontracts, including provider agreements, cannot extend beyond the term of the Contract between the Contractor and the State but may automatically renew consistent if the Contract is re-awarded by subsequent procurement. A reference to this provision and its requirements shall be included in all provider agreements and subcontracts.

FSSA must review and approve all subcontractors, with the exception of network healthcare providers or ancillary medical providers, and any change in subcontractors or material change to subcontracting agreements. Subcontracts with entities that are located outside of or will perform work outside of the United States and Territories of the

United States are prohibited. The Contractor must give FSSA a written request and submit a draft contractor or model provider agreement at least sixty (60) calendar days prior to the use of a subcontractor. If the Contractor makes subsequent changes to the duties included in the subcontractor agreement, it must notify FSSA sixty (60) calendar days prior to the revised effective date and submit the amendment for review and approval. FSSA must approve changes in vendors for any previously approved subcontracts. FSSA may waive its right to review subcontracts and material changes to subcontracts. Such waiver shall not constitute a waiver of any subcontract requirement.

The Contractor must have policies and procedures to audit and monitor subcontractors’ data, data submission and performance and must implement oversight mechanisms to monitor performance and compliance with Contract requirements. Further, the Contractor shall monitor the subcontractor’s performance on an ongoing basis. Formal reviews of subcontractors, excluding network healthcare providers or ancillary medical providers, must be conducted at least quarterly. FSSA reserves the right to audit subcontractor data and conduct onsite visits. Whenever deficiencies or areas of improvement are identified, the Contractor and subcontractor shall take corrective action. The Contractor shall provide to FSSA the findings of all subcontractor performance monitoring and reviews upon request and shall notify FSSA any time a subcontractor is placed on corrective action within five (5) business days of the subcontractor’s receipt of the corrective action notification. Additionally, FSSA shall establish and provide to the Contractor, through the Reporting Manual, any reporting requirements for incorporating subcontractor performance into the reports to be submitted to FSSA. The Contractor must integrate subcontractors’ financial and performance data (as appropriate) into the Contractor’s Information Technology (IT) systems to accurately and completely report Contractor performance and confirm compliance with the Contract.

The Contractor shall provide that all subcontracts related to the Contract, including, but not limited to subcontracts with other prepaid health plans, physician hospital -organizations, any entity performing delegated activities related to the Contract and any administrative entity not involved in the delivery of medical care, indemnify and hold harmless the State, its officers and employees from and against all claims, causes of action, damages, expenses, judgments and costs, including court costs, attorney’s fees and other expenses (“Losses”), directly or indirectly arising out of or in any way connected with any liability asserted by a third party related to injuries or damage received or sustained by any person, persons or property that is caused by an act or omission of the Contractor and/or the subcontractors. The Contractor agrees to indemnify and hold harmless the State, its officers and employees from all Losses arising out of

Contractor’s failure to include this required indemnity in its subcontracts. Notwithstanding the foregoing, this indemnification requirement does not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. The subcontracts must further provider that the State shall not provide such indemnification to the subcontractor.

Contractors that subcontract with prepaid health plans, physician-hospital organizations, dental benefits manager, transportation broker or another entity that accepts financial risk for services the Contractor does not directly provide must monitor the financial stability of subcontractor(s) whose payments are equal to or greater than five percent (5%) of premium/revenue. The Contractor must obtain the following information from the subcontractor at least quarterly and use it to monitor the subcontractor’s performance:

• A statement of revenues and expenses;

• A balance sheet;

• Cash flows and changes in equity/fund balance; and

• Incurred but not received (IBNR) estimates.

At least annually, the Contractor must obtain the following additional information from the subcontractor and use this information to monitor the subcontractor’s performance: (i) audited financial statements including statement of revenues and expenses; (ii) balance sheet; (iii) cash flows and changes in equity/fund balance; and (iv) an actuarial opinion of the IBNR estimates. The Contractor shall make these documents available to FSSA upon request.

The Contractor shall comply with 42 CFR 438.230, 42 CFR 434.6 and the following subcontracting requirements:

The Contractor shall obtain the explicit approval of FSSA before subcontracting any portion of the Contract’s requirements. Subcontractors may include, but are not limited to a transportation broker, behavioral health organizations (BHOs), and Physician Hospital Organizations (PHOs). The Contractor shall give FSSA a written request and submit a draft contract or model provider agreement at least sixty (60) calendar days prior to the use of a subcontractor. If the Contractor makes subsequent changes to the duties included in the subcontractor contract, it shall notify FSSA sixty (60) calendar days prior to the revised contract effective date and submit the amendment for review and approval. FSSA has sixty (60) days to complete a review and provide an approval or denial on the use of the subcontractor to the Contractor. FSSA must approve changes in vendors for any previously approved subcontracts.

The Contractor shall obtain the explicit approval of FSSA for all direct vendors and subcontractors performing services outlined in this Contract. FSSA must approve all revisions to the subcontracts as well. Only direct subcontractors and vendors require approval by the State (i.e. subcontractors of subcontractors do not require separate State approval).

The Contractor shall obtain approval from the State for all provider contract templates prior to use. This includes contract templates used by subcontractors.

The Contractor shall obtain approval from the State for any subcontractor(s) included in a proposed enhanced benefit.

The Contractor shall not subcontract with the External Quality Review (EQR) or Enrollment Broker contractors.

The Contractor must seek approval from the State for utilizing vendors for member outreach or to provide direct medical or behavioral care to members.

The Contractor is required to provide a report sixty (60) days after the end of each calendar year listing all such agreements. The report should include method of identifying members for the vendor, services provided, number of members for which each contracted vendor provided services, and standard demographics for the members who received the services.

The Contractor may not advertise or announce the new subcontractor relationship prior to FSSA’s approval of the subcontract. For subcontractors which result in a material change triggering member or provider notice, the sixty

(60) day FSSA review period for the subcontract, thirty (30) day period for document review, and thirty (30) or forty-five (45) day notice requirement may not run concurrently.

The Contractor shall evaluate prospective subcontractors’ abilities to perform delegated activities prior to contracting with the subcontractor to perform services associated with the Hoosier Care Connect program.

The Contractor shall have a written agreement in place that specifies the subcontractor’s responsibilities and provides an option for revoking delegation or imposing other sanctions if performance is inadequate per 42 CFR

438.230(c)(1)(iii). The written agreement shall be in compliance with all the State of Indiana statutes and will be subject to the provisions thereof. The subcontract cannot extend beyond the term of the State’s Contract with the Contractor.

The Contractor shall collect performance and financial data from its subcontractors and monitor delegated performance on an ongoing basis and conduct formal, periodic, and random reviews, as directed by FSSA. The

Contractor shall incorporate all subcontractors’ data into the Contractor’s performance and financial data for a comprehensive evaluation of the Contractor’s performance compliance and identify areas for its subcontractors’ improvement when appropriate. The Contractor shall take corrective action if deficiencies are identified during the review.

All subcontractors shall fulfill all State and federal requirements including Medicaid laws, regulations, applicable sub-regulatory guidance and contract provisions appropriate to the services or activities delegated under the subcontract. In addition, all subcontractors shall fulfill the requirements of the Contract (and any relevant amendments) that are appropriate to any service or activity delegated under the subcontract.

The Contractor shall submit a plan to the State on how the subcontractor will be monitored for debarred employees.

For the purposes of an audit, evaluation, or inspection by the State, CMS, the DHHS Inspector General, the Comptroller General or their designees, the subcontractor shall make available for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later, its premises, physical facilities, equipment, books, records contracts, computer, or other electronic systems relating to its Medicaid enrollees per 42 CFR

438.230(c)(3)(iii) and 42 CFR 438.3(k). This contract term shall specify that if the state, CMS, or the DHHS Inspector General determine that there is a reasonable possibility of fraud or similar risk, the above State and Federal agencies may inspect, evaluate, and audit the subcontractor at any time.

The Contractor shall comply with all subcontract requirements specified in 42 CFR 438.230, which contains federal subcontracting requirements. All subcontracts, provider contracts, agreements or other arrangements by which the Contractor intends to deliver services required under the Contract, whether or not characterized as a subcontract under the Contract, are subject to review and approval by FSSA and must be sufficient to assure the fulfillment of the requirements of 42 CFR 434.6, which addresses general requirements for all Medicaid contracts and subcontracts. FSSA may waive its right to review subcontracts, provider contracts, agreements or other arrangements. Such waiver shall not constitute a waiver of any subcontract requirement.

The subcontract shall specify the activities and obligations, and related reporting responsibilities per 42 CFR 438.230(c)(1)(i)-(ii) and 42 CFR 438.3(k).

OMPP reserves the right to audit the Contractor’s subcontractors’ self-reported data and change reporting requirements at any time with reasonable notice. OMPP may require corrective actions and will assess liquidated damages, as specified in Contract Exhibit 2.G Contract Compliance and Pay for Outcomes, for non-compliance with reporting requirements and performance standards.

The Contractor is prohibited from subcontracting with providers who have been excluded from the federal government or by the Indiana Health Coverage Program (IHCP) for fraud or abuse. The Contractor shall be responsible for checking the lists of providers currently excluded by the state and the federal government every thirty (30) calendar days. The federal list is available at: http://exclusions.oig.hhs.gov. As described in Section 6.0, all network providers must be IHCP enrolled providers. The Contractor shall ensure when the IHCP disenrolls a provider, the Contractor also terminates the provider agreement for the Hoosier Care Connect program.

While the Contractor may choose to subcontract claims processing functions, or portions of those functions, with a state-approved subcontractor, the Contractor shall demonstrate that the use of such subcontractors is invisible to providers, including out -of-network and self-referral providers, and will not result in confusion to the provider community about where to submit claims for payments. For example, the Contractor http://exclusions.oig.hhs.gov/ may elect to establish one post office box address for submission of all out -of-network provider claims.