503Anthem25Pathways AM01 82034.pdf

AMENDMENT #1

CONTRACT #0000000000000000000082034

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., d.b.a. Anthem Blue Cross and Blue Shield (the "Contractor"), approved by the last State signatory on May 15, 2024.

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 PathWays for Aging program is hereby amended to update Exhibits 1, 2, 3, 5, and 6. Unless otherwise noted, and subject to specific provisions within each Exhibit, this amendment shall be effective July 1, 2025.

Exhibit 1, which outlines the Scope of Work – Indiana PathWays for Aging, is hereby superseded and replaced by Exhibit 1.A, which is attached hereto and incorporated herein.

Exhibit 2, which outlines the Contract Compliance and Pay for Outcomes, is hereby superseded and replaced by Exhibit 2.A, which is attached hereto and incorporated herein.

Exhibit 3, which outlines the Program Description and Covered Benefits, is hereby superseded and replaced by Exhibit 3.A, which is attached hereto and incorporated herein.

Exhibit 5, which outlines the Contract Definitions, is hereby superseded and replaced by Exhibit

5.A, which is attached hereto and incorporated herein.

Exhibit 6, which outlines the Indiana PathWays for Aging Capitation Rates, is hereby superseded and replaced by Exhibit 6.A, which is attached hereto and incorporated herein.

Funding in the amount of $1,810,204,071.33 is being removed from the total contract amount.

Total remuneration for this contract shall not exceed $8,571,781,290.24.

Clause 18. Employment Eligibility Verification of the original Contract is deleted replaced in its entirety 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 agrees 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.

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.

Docusign Envelope ID: ECBE51E8-4F97-4887-81FF-5B29661CD8BA

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.

The Contractor’s Division of Supplier Diversity (“DSD”) ongoing obligations remain unchanged, 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 Division of Supplier Diversity 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 subcontractor(s) will be participating in this

Contract:

IVOSB # PHONE

COMPANY

NAME

SCOPE OF PRODUCTS

and/or SERVICES

UTILIZATION

DATE

PERCENT

0000054974 317.719.3895 Summit

Managed

Solutions LLC

Provide business and corporate management consultation services, management advisory services, sales and business promotion activities, sales or marketing programs, project management, and temporary personnel services.

7/1/2024- 6/30/2028

3.5%

A copy of each subcontractor agreement must be submit ted to the Division of Supplier Diversity 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-462, 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 certified 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 Division of Supplier Diversity, as reasonably requested and in the format required by the Division of Supplier Diversity.

mailto:IndianaVeteransPreference@idoa.IN.gov mailto:IndianaVeteransPreference@idoa.IN.gov http://www.in.gov/idoa/mwbe/payaudit.htm

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

B. 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 "Attachment A" in the procurement documentation and incorporated by reference herein. Therefore, any changes to this information during the Contract term must be approved by the Division of Supplier Diversity 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 Division of Supplier Diversity certified MBE and/or WBE subcontractors will be participating in this Contract:

MBE/WBE # PHONE COMPANY

NAME

SCOPE OF PRODUCTS and/or

SERVICES

UTILIZATION

DATE

PERCENT

0000055344 (317) 946-

Affirm Group Services, LLC

Provide business and corporate management consultation services, project management, management and business professionals and administrative services and sales and business promotion activities.

7/1/2024 – 6/30/2028

0.76%

0000056805 (317) 541-

BKG

Enterprises, Inc.

Provide management and business professionals and administrative services, staff recruiting services, temporary personnel services, and strategic planning consultation services requirements

7/1/2024 – 6/30/2028

8.00%

0000019230 (317) 610-

DaMar Staffing Solutions of

Indianapolis, Inc

Provide personnel recruitment and temporary personnel services.

7/1/2024 – 6/30/2028

1.75%

0000015988 (317) 488-

Professional Management

Enterprises, Inc.

Provide logistics operations management for nonemergency medical transportation (NEMT);

passenger transport; project management and temporary personnel services

7/1/2024 – 6/30/2028

11.51%

0000027711 (317) 456-

Sahasra Technologies Corp. dba

STLogics

Provide education and training services, strategic planning consultation services, permanent medical staff needs, temporary medical staffing needs, temporary personnel services and management and business professionals and administrative services

7/1/2024 – 6/30/2028

1.00%

A copy of each subcontractor agreement must be submitted to the Division of Supplier Diversity 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 the Division of Supplier Diversity, 402 W.

Washington Street, Room W-462, 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 of Supplier Diversity 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 of Supplier Diversity certified subcontractor payments directly to the Division, as reasonably requested and in the format required by the Division of Supplier Diversity.

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 deleted and the following substituted therefore:

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

220 Virgina 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 not affected by this Amendment shall remain in full force and effect.

mailto:MWBECompliance@idoa.IN.gov mailto:MWBECompliance@idoa.IN.gov http://www.in.gov/idoa/mwbe/payaudit.htm mailto:mitch.roob@fssa.IN.gov mailto:KLynn.Scott@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 signatures dated below agree to the terms thereof.

Anthem Insurance Companies, Inc. Indiana Family and Social Services Administration, d.b.a. Anthem Blue Cross and Blue Shield Office of Medicaid Policy and Planning

By:\s1\ By:\s2\

Title:\t1\ Title:\t2\

Date:\d1\ Date:\d2\

Electronically Approved by:

Indiana Office of Technology

By: (for) Jeffrey K. Allen, Acting Chief Information Officer

Department of Administration

Brandon Clifton, Commissioner

State Budget Agency

Chad Ranney, State Budget Director

Electronically Approved as to Form and Legality:

Off ice of the Attorney General

Theodore E. Rokita, Attorney General

President, Indiana Medicaid

6/19/2025 | 12:17 EDT 6/20/2025 | 13:16 PDT

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

EXHIBIT 1.A

SCOPE OF WORK - INDIANA PATHWAYS FOR AGING

TABLE OF CONTENTS

1.0 Background

1.1 Indiana PathWays for Aging (PathWays) Quality Goals

2.0 Administrative Requirements

2.1 Eligibility Requirements

2.1.1 Eligibility Determination Process

2.1.2 Long-Term Care Functional Screen

2.2 State Licensure

2.3 National Committee for Quality Assurance (NCQA) Accreditation

2.4 Administrative and Organizational Structure

2.4.1 Staffing

2.4.2 Key Staff

2.4.3 Other Required Staff Positions

2.4.4 Additionally Required Staff Positions

2.4.5 Staff Training and Qualifications

2.5 Debarred Individuals

2.6 FSSA Meeting Requirements

2.7 Financial Stability

2.7.1 Solvency

2.7.2 Insurance Requirements

2.7.3 Reinsurance

2.7.4 Financial Accounting Requirements

2.7.5 Reporting Transactions with Parties of Interest

2.7.6 Compensation

2.7.7 Medical Loss Ratio (MLR)

2.8 Supplemental Payments and Directed Payments

2.8.1 Hospital Assessment Fee

2.8.2 Physician Faculty Access to Care (PFAC) Program

2.8.3 Nursing Facility Supplemental Payments

2.8.4 LTSS and HCBS Minimum Fee Schedule

2.8.5 Physician and Ancillary Minimum Fee Schedule

2.9 Subcontracts

2.10 Confidentiality of Member Medical Records and Other Information

2.11 Internet Quorum (IQ) Inquiries

2.12 Material Change to Operations

2.13 Future Program Guidance

2.14 Conflict of Interest

2.15 Capitation Related to a Vacated Program

2.16 Maintenance of Records

2.17 Maintenance of Written Policies and Procedures

2.18 Participation in Readiness Review

2.19 Dissemination of Information

2.20 Access to Premises and Information

2.20.1. Access to Premises

2.20.2 Access to and Audit of Contract Records

2.21 Integration and Alignment of Medicare and Medicaid

2.21.1 Coordination with Medicare Generally

2.21.2 Dual Eligible Special Needs Plan (D-SNPs) Requirements and Coordination66

3.0 Covered Benefits and Services

3.1 Covered Benefits and Services

3.2 Self-referral Services

3.3 Drug Coverage

3.3.1 Drug Rebates

3.3.2 SUPDL and Formulary Requirements

3.3.3 DUR Board Reporting Requirements

3.3.4 Dispensing and Monitoring Requirements

3.3.5 E-Prescribing

3.3.6 Carve-Out of Select Drugs

3.3.7 SUPPORT Act Compliance

3.3.8 Medicare Part D

3.3.9 Long Term Care and Pharmacy

3.3.10 Pharmacy Benefit Manager Contracting

3.4 Emergency Services

3.4.1 Post-Stabilization Services

3.5 Smoking Cessation and Tobacco Dependence Treatment

3.6 Behavioral Health

3.6.1 Behavioral Health Care Services

3.6.2 Behavioral Health Provider Network

3.6.3 Care Coordination and Service Coordination for Members Receiving

Behavioral Health Services

3.6.4 Behavioral Health Care Coordination

3.6.5 Behavioral Health Continuity of Care

3.6.6 Institution for Mental Disease (IMD)

3.7 Prevention and Wellness

3.7.1 Prevention and Wellness Plan

3.7.2 Prevention and Wellness Program

3.8 State Plan Authority Long Term Services and Supports

3.8.1 Nursing Facility

3.8.2 Home Health

3.8.3 Hospice

3.9 Home and Community Based Services (HCBS)

3.10 Participant-Directed Attendant Care Services (PDACS)

3.11 Informal Caregiver Support

3.11.1 Informal Caregiver Training, Education, and Resources

3.11.2 Caregiver Coaching

3.12 Housing

3.13 Medical Equipment

3.14 24-hour Nurse Call Line

3.15 Opioid Treatment Program (OTP)

3.16 Dental Services

3.17 Non-Emergency Medical Transportation Services

3.17.1 Non-emergency Medical Transportation Providers and Provider Network . 106

3.17.2 NEMT Care Coordination

3.17.3 NEMT Communications

3.17.4 NEMT Brokers

3.17.5 Community Transportation

3.17.6 Attendant Care Aide Transportation

3.18 Diabetes Supplies Coverage

3.19 Service Delivery Innovation

3.20 Carved-out Services

3.20.1 Medicaid Rehabilitation Option (MRO) Services

3.20.2 1915(i) State Plan Home and Community-Based Services

3.21 Excluded Services

3.21.1 Psychiatric Treatment in a State Hospital

3.21.2 Intermediate Care Facilities for Individuals with Intellectual Disabilities

3.21.3 Traumatic Brain Injury Waiver

3.21.4 Community Integration and Habilitation Waiver

3.21.5 Family Supports Waiver

3.22 Continuity of Care

3.23 Out-of-Network Services

3.24 Enhanced Services

3.25 Residential Substance Use Disorder (SUD) Services

3.26 Inpatient Hospitalization Notification

3.27 Medication Therapy Management Services

3.27.1 Goals of the MTM Program

3.27.2 General Requirements

3.27.3 Comprehensive Medication Review (CMR)

3.27.4 Target Members

3.27.5 Reporting

4.0 Care Coordination

4.1 Care Coordination Program Overview

4.2 Care Coordination Levels of Service and Stratification

4.2.1 Care Management

4.2.2 Complex Case Management

4.2.3 Complex Case Management and Service Coordination

4.2.4 Right Choices Program

4.3 MLTSS and Medicare Care Coordination Alignment

4.4 Subpopulations at Greater Risk for Negative Health Outcomes

4.4.1 State-identified Members at Greater Risk for Negative Health Outcomes .. 125

4.5 Initial Screening

4.6 Comprehensive Health Assessment

4.7 Reassessments

4.8 LTSS-specific Assessments

4.8.1 Nursing Facility Assessments

4.8.2 Informal Caregiver Assessments

4.9 Individualized Care Plans

4.9.1 Care Management – Individualized Care Plan Requirements

4.9.2 Complex Case Management – Individualized Care Plan Requirements

4.9.3 Individualized Care Plan Documentation and Distribution

4.10 Service Plan

4.10.1 Assisted Living and Community Home Share Service Planning

4.10.2 Nursing Facility Service Plans

4.10.3 Service Plan Signatures

4.10.4 Service Plan Authorization

4.10.5 Service Plan Timeline Requirements

4.10.6 Service Plan Timeline Requirements – Program Implementation

4.10.7 Service Plan Monitoring

4.11 Minimum Member Contact

4.11.1 Care Management – Member Outreach and Contact

4.11.2 Complex Case Management – Member Outreach and Contact

4.11.3 Service Coordination – HCBS Minimum Contacts

4.11.4 Service Coordination – NF Minimum Contacts

4.11.5 Documentation of Contact

4.12 Transitions

4.12.1 Relocation Targeted Case Management

4.12.2 Nursing Facility-to-Community Transitions

4.12.3 Inpatient Hospitalizations

4.12.4 Housing Supports

4.12.5 Member Information and Care Plan Transfer

4.12.6 Transitions and Discharge Planning due to Provider Facility Closures and License Termination

4.13 Care Coordinator Requirements

4.13.1 Care Coordinator Assignment

4.13.2 Person Centered Practices Training

4.13.3 Care Coordinator Training Requirements

4.14 Service Coordinator Requirements

4.14.1 Service Coordinator Selection

4.14.2 Person-Centered Practices Training

4.14.3 Service Coordinator Training Requirements

4.15 Care Coordinator Caseload Requirements

4.16 Service Coordinator Caseload Requirements

4.16.1 Service Coordinator for NF Residents

4.17 Interdisciplinary Care Team (ICT)

4.17.1 ICT Participants

4.17.2 ICT Participant Roles and Responsibilities

4.17.3 ICT Communication Plan

4.18 Care Coordination and Service Coordination Performance and Monitoring

4.18.1 Contractor Collaboration

4.18.2 Contractor Cooperation

4.18.3 Care Plan Audits and Service Plan Reporting

4.18.4 Care Coordination/Service Coordination Reviews

4.18.5 Care Coordination Program Monitoring

5.0 Member Services

5.1 Marketing and Outreach

5.2 Member Enrollment and Contractor Selection

5.2.1 Enrollment and Practice Discrimination

5.2.2 Enrollment Packet

5.2.3 PMP Selection

5.2.4 Provider Network and Provider Directory Information

5.2.5 Member Disenrollment from MCE

5.3 Member-Contractor Communications

5.3.1 Member Services Helpline and 24-Hour Nurse Line

5.3.2 Electronic Communications

5.4 Member Information, Education, and Outreach

5.5 Member and Stakeholder Education and Engagement

5.6 Member ID Card

5.7 Member Materials

5.7.1 Member Welcome Letter

5.7.2 Member Handbook

5.7.3 Member Website

5.7.4 Preventive Care Information

5.7.5 Member Education

5.7.6 Cost and Quality Information

5.8 Member and Potential Member Communications Review and Approval

5.9 Redetermination Assistance

5.10 Member-Provider Communications

5.11 Member Rights

5.12 Additional Information Available Upon Request

5.13 Procedures Regarding Potential Abuse, Neglect, and Exploitation (ANE) of Older Adults ……………………………………………………………………………………..190

5.13.1 Contractor Responsibility

5.13.2 ANE Policies and Procedures

5.13.3 Access to Adult Protective Services (APS), Long-Term Care (LTC) Ombudsman Program, and Member Support Services

5.13.4 ANE Examination and Treatment Services by Providers

5.13.5 Outreach to Adult Protective Services, Long-Term Care Ombudsman, and Member Support Services

5.14 Member Inquiries, Grievances & Appeals

5.14.1 Contractor Grievance and Appeals Policies

5.14.2 Inquiry Processing Requirements

5.14.3 Grievance Processing Requirements

5.14.4 Appeals Processing Requirements

5.14.5 External Review by Independent Review Organization

5.14.6 State Fair Hearing Process

5.14.7 Continuation of Benefits Pending Appeal & Reinstatement of Benefits

5.14.8 Member Notices of Action & Grievance, Appeal and Fair Hearing Procedures …………………………………………………………………………………...200

5.14.9 Member Support Services

5.15 Oral Interpretation Services

5.16 Health Equity

5.17 Advance Directive Information

6.0 General Provider Network Requirements

6.1 General Network Development and Management Plan

6.1.1 LTSS Network Development and Management Plan

6.1.2 Access to Culturally and Linguistically Competent Providers

6.2 Network Composition Requirements

6.2.1 Acute Care Hospital Facilities

6.2.2 Primary Medical Providers (PMP)

6.2.3 Specialist and Ancillary Providers

6.2.4 Pharmacy Services

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

6.2.6 Inpatient Psychiatric Facilities

6.2.7 SUD Providers

6.2.8 Dental Providers

6.2.9 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics

(RHCs)…

6.2.10 Indian Healthcare Providers

6.2.11 County Health Departments

6.2.12 Urgent Care Clinics

6.2.13 Dialysis Treatment Center

6.2.14 Gynecologists

6.2.15 Non-Emergency Medical Transportation Providers

6.2.16 Physician Extenders

6.2.17 Skilled Nursing Facilities

6.2.18 LTSS Providers

6.2.19 Telehealth

6.2.20 Remote Technology

6.3 Workforce Development

6.4 Provider Accessibility

6.5 Provider Qualifications and Standards

6.6 Provider Enrollment and Disenrollment

6.6.1 Provider Network Change Procedures

6.7 Provider Credentialing

6.8 Provider Referrals

6.9 Provider Agreements

6.10 Medical Records

6.11 Provider Education and Outreach

6.11.1 Provider Communications Review and Approval

6.11.2 Provider Policy and Procedures Manual

6.11.3 Provider Dispute Resolution

6.11.4 LTSS Provider Engagement

6.12 Contractor Communications with Providers

6.12.1 Provider Website

6.12.2 Provider Newsletters

6.12.3 Provider Services Helpline

6.12.4 IHCP Workshops and Seminars

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

…………………………………………………………………………………..…………..239

6.14 Member Payment Liability

6.15 Provider Directory

7.0 Quality Improvement

7.1 Quality Management and Improvement Program

7.1.1 Scope and Standards

7.1.2 Quality Management and Improvement Program Requirements

7.1.3 Annual Quality Management and Improvement Program Work Plan Requirements

7.1.4 Staff and Delegation of Quality Program Activities

7.1.5 Quality Management and Improvement Committees

7.1.6 Annual Quality Management and Improvement Program Evaluation and

Update

7.1.7 Annual Quality Management and Improvement Program Workgroup

7.1.8 Information System & Data Collection to Support Quality

7.1.9 External Quality Review

7.1.10 Cooperation with the State

7.1.11 Publication of Quality Performance Reports

7.1.12 HEDIS Audit

7.1.13 Waiver Assurances

7.1.14 Incident Reporting and Management

7.2 Surveys

7.2.1 Consumer Assessment of Healthcare Providers and Systems (CAHPS) ... 261

7.2.2 National Core Indicators Survey- Aging and Disabilities (NCI-AD)

7.2.3 Caregiver Survey

7.2.4 Provider Surveys

7.2.5 Additional Surveys

7.3 Value Based Payment (VBP)

7.3.1 VBP Program Design

7.3.2 VBP Program Participation

7.3.3 VBP Metrics and Reporting

7.4 Pay-for-Outcomes Quality Incentive Programs

7.5 Provider Feedback Reporting and Technical Assistance

7.5.1 Technical assistance components

7.5.2 Jointly developed technical assistance

7.6 Provider Incentive Programs

7.7 Member Incentive Programs

7.7.1 Required Member Incentives

7.7.2 Optional Member Incentives

7.8 Utilization Management Program

7.8.1 Utilization Management Staffing and Training

7.8.2 Medical Service and Pharmacy Prior Authorization (Non-HCBS Services) 270

7.8.3 Special Consideration for Long Term Services and Supports (LTSS) Service Authorization

7.8.4 Special Consideration for Home and Community Based Services (HCBS) Service Authorization

7.8.5 Authorization of Services and Notices of Actions

7.8.6 Authorization Systems and Technology

7.8.7 Referral Requirements

7.8.8 Objection on Moral or Religious Grounds

7.8.9 Utilization Management Committee

8.0 Program Integrity

8.1 Program Integrity Plan

8.2 Program Integrity Operations

8.3 Program Integrity Reporting

8.4 Program Integrity Overpayment Recovery

8.5 Auditing Program Integrity Operations

8.6 Long Term Services and Supports

9.0 Information Technology (IT) Systems

9.1 Testing with the State

9.2 Master Test Plan

9.3 Business Contingency and Disaster Recovery Plans

9.4 Member Enrollment Data Exchange

9.5 Provider Network Data

9.6 Health Information Technology and Interoperability

9.7 Claims Processing

9.7.1 Claims Processing Capability

9.7.2 Compliance with State and Federal Claims Processing Regulations

9.7.3 Claims Payment Timelines

9.7.4 Rate Update Timeliness

9.7.5 Medicaid National Correct Coding Initiative (NCCI)

9.7.6 Claims System Audits

9.7.7 Claims System Changes

9.7.8 Claims Reports

9.8 Encounter Data Submission

9.8.1 Definition and Uses of Encounter Data

9.8.2 Reporting Format and Batch Submission Schedule

9.8.3 Encounter Claims Quality

9.9 Coordination of Benefits and Third-Party Liability (TPL)

9.9.1 Collection and Reporting

9.9.2 Cost Avoidance

9.9.3 Retroactive Medicare Coverage

9.9.4 Cost Avoidance Exceptions

9.9.5 TPL Special Circumstances

9.10 Electronic Visit Verification (EVV) Requirements

10.0 Performance Reporting and Incentives

10.1 Financial Reports

10.2 Member Service Reports

10.3 Network Development Reports

10.4 Provider Service Reports

10.5 Quality Management Reports

10.6 Utilization and Authorization Reports

10.7 Claims Reports

10.8 Care Coordination and Service Coordination Reporting

10.9 Health Outcomes and Clinical Reporting

10.10 CMS Reporting

10.11 Other Reporting

11.0 Failure to Perform/Non-compliance Remedies

11.1 Non-compliance Remedies

11.2 Evidence of Financial Responsibility

12.0 Termination Provisions

12.1 Contract Terminations

12.1.1 Termination by the State for Contractor Default

12.1.2 Termination for Financial Instability

12.1.3 Termination for Failure to Disclose Records

12.1.4 Termination by the Contractor

12.2 Termination Procedures

12.3 Contractor Responsibilities upon Termination or Expiration o f the Contract

12.4 Damages

12.5 Assignment of Terminating Contractor’s Membership and Responsibilities

12.6 Refunds of Advanced Payments

12.7 Termination Claims

This Scope of Work is part of a Contract to provide statewide, risk-based managed care services to Medicaid beneficiaries enrolled in the State of Indiana’s PathWays for Aging (PathWays) program. The State is soliciting proposals from proven managed care entities (MCEs) to coordinate and provide member-driven, accessible, equitable and high-quality services to eligible Medicaid members for medical, behavioral, and long-term services and supports.

Because PathWays is financed in part by federal Medicaid funds, Contractors shall meet all applicable requirements of Medicaid managed care organizations under Section 1903(m) and 1932 of the Social Security Act, as well as the implementing regulations set forth in 42 CFR 438 , which defines requirements for Medicaid managed care programs. Contractors shall also ensure that its network providers, including out-of-state providers, enroll in the Indiana Health Coverage Programs (IHCP) before they begin providing health care services to members. Further information about IHCP provider enrollment is located at:

https://www.in.gov/medicaid/providers/provider-enrollment/become-a-provider/

Unless otherwise indicated, the requirements set forth in this Scope of Work apply to the Contractor’s responsibilities under the PathWays program. Definitions for terms cited throughout the Scope of Work are listed in Exhibit 5A unless otherwise specified.

1.0 Background

The Indiana Family and Social Services Administration (FSSA) manages the PathWays program, which will serve approximately 106,0001 Hoosiers. Indiana’s PathWays program is a statewide coordinated care program for Indiana’s Medicaid enrollees who are 60 years of age and older and are eligible for Medicaid on the basis of age, blindness, or disability and have limited income and resources. All individuals who are 60 years of age or older in the target eligibility categories will be included unless they meet an exclusion, as specified in Exhibit 3A. Enrollees include members who have a full Medicare benefit, those in a nursing facility, and those who are receiving long-term services and supports (LTSS) in a home or community-based setting.

The State is interested in contracting with MCEs that can perform the administrative functions of a typical insurer, can support members in strategies to address complex and chronic health conditions of the program population which includes many individuals with complex health conditions who are dually eligible for Medicare and Medicaid and/or receive LTSS, and can manage and integrate care along the continuum and settings of LTSS in Indiana.

In developing PathWays, FSSA seeks to achieve the following:

Ensure more Hoosiers can choose to age at home and simplify access to Home and Community-Based Services (HCBS)

Appropriately divert individuals from long-term nursing facility stays in accordance with a person-centered approach. Through high-quality care coordination, coordinated care across the delivery system and care continuum, including across Medicaid and Medicare for dually eligible members, and taking into account physical health, behavioral health, and social services

Improve quality outcomes and consistency of care across the delivery system

Provide person-centered and strengths-based care

1 The enrollment f igures provided in this Scope of Work are current f igures only. Enrollment in the PathWays program may increase or decrease in the future based upon federal policies, program priorities, available funding, etc.

https://www.in.gov/medicaid/providers/provider-enrollment/become-a-provider/

Ensure member choice, protections, and access

Promote caregiver support and skill development

Emphasize communication, training, and collaboration with network providers to ease administrative burden and help accomplish program goals

Align incentives across the delivery system with improved health and quality of life outcomes

Deliver cost-effective and accountable coverage

Leverage data to make informed program and care decisions

Understand, measure, and address health inequities in care and access

Promote primary and preventive care

Ensure the appropriate use of health care services

Develop informed health care consumers by increasing health literacy and providing price and quality transparency of members and their informal caregivers

Encourage quality, continuity, and appropriateness of medical care

Develop innovative member and provider incentives

Develop innovative utilization management techniques that incorporate member and provider education to facilitate the right care, at the right time, in the right location

Engage in provider and member outreach regarding preventive care, wellness, and a holistic approach

Expand the HCBS provider network, especially in rural areas

The Contractor shall ensure that they follow all program requirements and guidance issued by the

State including but not limited to the PathWays MCE Policies and Procedures Manual as updated and amended periodically.

1.1 Indiana PathWays for Aging (PathWays) Quality Goals

The Contractor shall be required to help lead the transformation of our Medicaid LTSS delivery system and to collaborate with the State and other PathWays MCEs to achieve this mission. The contractor shall abide by the requirements further detailed in Section 7.0

Quality Improvement. The State has established three overarching Program Quality Goals for the PathWays:

The State wants to encourage ongoing investment and achieve lasting progress, therefore FSSA is committed to maintaining these goals for the first contract term and potential contract term extension years of the PathWays program. For each goal, FSSA will establish focus areas, objectives, and performance targets which will evolve over time to reflect the maturation of the PathWays and MCEs. The Contractor will be expected to develop and accomplish annual workplans and make investments toward improved outcomes. Measures associated with certain objectives will also be identified as Pay for Outcomes measures, and the Contractors’ performance on all quality goals will be shared publicly.

The PathWays Program Quality Goals were developed with broad input from Indiana stakeholders

– including members and member advocates – and are reflective of national best practices. These goals will also build a strong foundation for Indiana to effectively deliver and finance PathWays services, provide the best value to program members and Hoosier taxpayers, and produce improved program outcomes. The State believes that achieving these goals will be a win-win for all involved parties:

For members, who will have increased choice and access to services as well as increased control over their services and supports;

For providers, who will have clear, consistent messaging about program priorities and technical assistance and training to help them deliver services and supports in a manner that supports those priorities; and

For MCEs, who will, through collaborative and aligned efforts, be able to more effectively support provider and member behavior change to achieve improved results.

MCE Investments in Quality

These overarching PathWays Quality Goals reflect the State’s highest priorities. As such, FSSA intends to award contracts to Contractors that offer innovative and evidence-based approaches in meeting these PathWays Goals. The State expects Contractors to align their resources toward achieving improvement in these goal areas. Examples include:

Member and provider outreach and education efforts should support the goals

In lieu of services and enhanced services offered by the MCE should be carefully selected to support these goals

Member and provider incentives and Value-Based Purchasing arrangements should be designed to support these goals

FSSA PathWays Program Quality Goals

Goal 1: Person-Centered Services and Supports – Develop service plans and deliver services in a manner that is person-centered, member-driven, holistic, involves caregivers, and addresses SDOH.

Goal 2: Ensuring Smooth Transitions – Ensure continuity of care and seamless experiences for members as they transition into the Pathways program or among providers, settings, or coverage types.

Goal 3: Access to Services (Member Choice) – Assure timely access to appropriate services and supports to enable members to live in their setting of choice and promote their well-being and quality of life.

The Contractor will be required to actively collaborate with the State and other PathWays Contractors to design and implement initiatives and interventions that support these goals. This collaboration will be achieved through participation in formal committees and workgroups facilitated by the State, as well as by the execution of common strategies across MCEs. MCEs will be expected to share insights and best practices and to actively participate in and contribute to these quality improvement activities.

Focus Areas for Future Years

Member experience is an important component of our initial focus and will continue to be in future years because member experiences serve as an important indicator of the quality of services provided by the MCEs. Examples of other focus areas (not listed in order of priority) to support the PathWays Program Quality Goals, that were suggested by stakeholders for possible inclusion in future years:

Person-Centered Services and Supports

Possible Future Focus Areas: Coordination between Medicaid MCE and D-SNPs/other Medicare plans; Member goal attainment (LTSS and non-LTSS); Advance care planning and palliative care

Ensuring Smooth Transitions

Possible Future Focus Areas: Transitions among settings (Hospital, NF, HCBS); Transitions between MCEs/Medicare health plans; Members newly eligible for Medicare; Transitions from nursing facility to HCBS (when chosen by the member); Use of event notification system;

Medicare-Medicaid Care Coordination; Completeness and accuracy of options counseling (transitions into LTSS)

Access to Services (Member Choice)

Possible Future Focus Areas: Direct service worker workforce initiatives; Home Health nursing workforce initiatives; Timely member access to HCBS; Availability of informal caregiver supports;

Connections with social determinants of health (SDOH) and closed-loop referrals; HCBS utilization; Potentially preventable events and/or adult core measures (as an indicator of access to preventive care); Primary care visits; Community inclusion; Healthy days at home; Loneliness assessment

Initial Objectives for PathWays Program Quality Goals

To actively support the PathWays Program Quality Goals, we have developed measurable objectives and performance targets that each of the MCEs will be required to meet. Certain objectives have been designated as Pay for Outcomes measures. For those measures, higher incentive payments will be made to MCEs that reach targets above the benchmarks identified in the Pay for Outcomes in Exhibit 2A.

These initial focus areas and objectives were designed to focus on building infrastructure that will enable the State to more effectively manage and deliver care and services in future years. Thus, the initial objectives largely rely on structural and process measures.

2.0 Administrative Requirements

2.1 Eligibility Requirements

The State has sole authority for determining whether individuals meet the eligibility criteria of the PathWays program. The FSSA Division of Family Resources (DFR) makes Medicaid eligibility determinations based on federal and state policy as interpreted by OMPP. Nursing Facility Level of care is determined based on state law and administrative rule.

Age and Target Group

In order to be eligible to enroll in an MCE, an individual must be in the age and target groups served by the MCE as specified below.

Medicaid Eligibility

The population for this program is individuals 60 and older who are eligible for Medicaid on the basis of age, blindness, or disability and have limited income and resources. All members aged 60 and older in the target eligibility categories will be included unless the individual meets an exclusion. This includes members who have a full Medicare benefit and those in a nursing facility.

Included Individuals aged 60 years of age or over who are enrolled in

Medicaid based on eligibility as:

Aged (MA A)

Blind (MA B) Disabled (MA D) SSI recipients (MASI)

MED Works (MADW, MADI) Full-Benefit Dually-Eligible individuals (QMB-also, SLMB-also, and

FBDE)

Including those who are:

-In a nursing facility -Receiving hospice services

Excluded -Partial Benefit Dually-Eligible individuals (QMB-only, SLMB-only, QI, QDWI)

-Anyone under 60 years of age -Anyone under 60 years of age on the Health and Wellness waiver, in a nursing home, or receiving hospice care -DDRS Waiver Recipients -PACE Members

-Room and Board RCAP members -ESRD 1115 members -Breast and Cervical Cancer Eligible members (MA 12)

-TBI Waiver Recipients -TBI Out of State Placements -ICF/IDD residents

-Emergency Services Only Members -Family Planning Only Members -HIP members with MAGI eligibility

-HHW members with MAGI eligibility -Registered members of a federally-recognized Tribe who are eligible for HIP but have opted out into FFS coverage (MANA)

Functional Eligibility

Functional eligibility is determined using the InterRAI assessment.

o In order to be functionally eligible for Long-Term Services and Supports an otherwise eligible individual must have a nursing facility level of care as determined by the InterRAI assessment and meet the requirements under Indiana Code 12-10-11.5-4. This level of care will be completed by an Enrollment Contractor selected by FSSA. Managed Care Entities will not determine the member’s level of care. For nursing facility admittance only, if the individual is reasonably expected to no longer meet nursing facility level of care within a time period of 30, 60, 90, or 120 days the nursing facility level of care must be reassessed in that respective time period. Additionally, for anyone receiving LTSS, the nursing facility level of care must be reassessed at least annually. The benefit package available to members is identified in Exhibit 3A Covered Benefits.

Residency

To be eligible for PathWays, an otherwise eligible individual must be a resident, as determined by DFR using rules found in the Indiana Health Coverage Policy & Program Manual (https://www.in.gov/fssa/ompp/forms-documents-and-tools2/medicaid-eligibility-policy-manual/).

MCE Assignment

For individuals who come into the program with no current Medicaid coverage, MCE assignment will be effective on the date of eligibility approval. Medicaid coverage may be effective up to three (3) months retroactively from their application date. Retroactive coverage will be in the fee for service (FFS) program, the managed care assignment will not be retroactive.

Individuals transitioning from an existing Medicaid Managed Care program or FFS, MCE assignment will be effective the first day of the month following the notice of change in eligibility.

Plan selection can be made while pending enrollment in PathWays. The enrollment broker will be responsible for providing choice counseling to the member. If a member does not select a plan there will be an assignment process in place directed by the State. Plan assignment will favor plan alignment between Medicare and Medicaid to the greatest extent allowable. Other factors may be considered such as the residential provider of the member (if applicable). See

Member Disenrollment from MCE (Section 5.2.5) for members’ rights to disenroll and change MCEs.

Medicare Election o To enroll, a prospective member who is eligible for Medicare must:

Enroll in and remain enrolled in all parts of Medicare for which the prospective member is eligible (Medicare Part A, Part B, and/or

Part D); or

Obtain all Medicare Part A, Part B, and Part D benefits, if eligible, from the MCE’s Special Needs Plan.

o If a member becomes Medicare-eligible after enrollment, the member

Docusign Envelope ID: ECBE51E8-4F97-4887-81FF-5B29661CD8BA https://www.in.gov/fssa/ompp/forms-documents-and-tools2/medicaid-eligibility-policy-manual/ https://www.in.gov/fssa/ompp/forms-documents-and-tools2/medicaid-eligibility-policy-manual/ must enroll in all parts of Medicare for which the member is eligible.

2.1.1 Eligibility Determination Process

1. Eligibility Determination Prior to Initial Enrollment

a. The Contractor will assure the Contractor’s separation from the FSSA initial eligibility determination and enrollment counseling functions. The separation shall meet criteria established by the State in accordance with applicable federal and state guidelines.

b. Contractors may market directly to members or potential members only in accordance with a marketing plan that has been approved by the State and may use only marketing materials that have been approved by the State.

2. Functional Eligibility Re-determination

Once enrolled, the Contractor is responsible to assure that all members have a current and accurate level of care as determined by the

InterRAI, in accordance with Section 2.1.2 Long-Term Care Functional Screen. This includes at minimum an annual re-determination of level of care. It may also include a post-enrollment re-determination shortly after enrollment or a re-determination necessitated by a change in the member’s condition. The Contractor shall not complete the level of care determination but work with the FSSA Enrollment Contractor and member to have the level of care determined annually and when a change in the member’s condition occurs.

3. Supporting Members to Maintain Medicaid Eligibility

The Contractor is responsible for supporting members with maintaining Medicaid eligibility. This includes but is not limited to:

a. Reminding members of the required annual Medicaid recertification procedure and coordinating member transportation to any needed DFR appointments;

b. Educate members on any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements;

c. Educate members on any deductible, cost share, patient or waiver liability obligation, or transfer penalty period they may need to meet to maintain Medicaid eligibility;

d. If appropriate and needed, supporting members to obtain a representative payee or legal decision maker; and

e. Referring and connecting members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations.

4. Providing Information that May Affect Eligibility

Members have a responsibility to report changes in circumstances that may affect Medicaid eligibility to DFR within ten (10) calendar days of the change. The Contractor is expected to be knowledgeable of eligibility criteria and educate members in reporting known changes to the DFR.

Notwithstanding the member’s reporting obligations, if the Contractor has information about a change in member circumstances that may affect Medicaid eligibility, the Contractor is to provide that information to DFR as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Section 5.2 Member Enrollment and Contractor Selection).

Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than DFR. The Contractor shall support members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility.

Reportable information includes:

An initial LOC determination that qualifies an individual for additional LTSS services or a change in a member’s LOC

The member has died

The member has been incarcerated

The member has a verified move either within the state or to another state

Any known changes in the member’s income or assets

Changes in the member’s marital status

5. Medicare Coverage Elections

The Contractor is responsible for having the requisite staff knowledge and resources to support members in effectively understanding any

Medicare coverage choices, including traditional Medicare, Medicare Advantage (non-special needs plans), and Special Needs Plans (SNPs) as well as all relevant Medicare enrollment periods, including the Open Enrollment Period (OEP) and Special Enrollment Periods (SEPs) in order to avoid unintended misalignment or even potential disenrollment from the program.

6. Waiver or Patient Liability

The Contractor is responsible for the ongoing monitoring of the waiver or patient liability amounts of its members. The Contractor is to receive and monitor medical claim amounts and apply allowable costs against the liability to ensure member responsibility is met; and to cover allowable costs after the liability is met.

Members may be required to pay a monthly waiver or patient…