503MHS23HHW AM04 69680.pdf

AMENDMENT #4

CONTRACT #0000000000000000000069680

This is an amendment to the Contract (the "Contract") entered into by and between the Indiana Family and Social Services Administration Office of Medicaid Policy and Planning (“FSSA” or “OMPP” or the "State") and Coordinated Care Corporation d/b/a Managed Health Services (the "Contractor"), approved by the last State signatory on March 21, 2023.

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 Healthwise program is hereby amended to update Exhibits 1.C, 2.C, 5.C, and 6.B. Unless otherwise noted, and subject to specific provisions within each Exhibit, this amendment shall be effective January 1, 2026.

Exhibit 1.C, which outlines the Scope of Work, is hereby superseded and replaced by Exhibit

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

Exhibit 2.C, which outlines the Contract Compliance and Pay for Outcomes is hereby superseded and replaced by Exhibit 2.D, which is attached hereto and incorporated herein.

Exhibit 5.C, which outlines the Contract Definitions, is hereby superseded and replaced by

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

Exhibit 6.B, which outlines the State’s Capitation Rates, is hereby superseded and replaced by

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

Funding in the amount of $245,502,869.12 is being added to the total contract amount. Total remuneration under the Contract is not to exceed $2,793,370,028.62.

Clause 18 “Employment Eligibility Verification” is hereby superseded and replaced by:

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.

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: FF0CFB9D-3DFE-4B3A-B000-4D7FF09FEC38

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:

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:

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.

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.

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

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 certi ficate 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:

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 t he 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) 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 work force. 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 establish an employment relationship between the State and any applicant or employee of the Contractor or any subcontractor.

mailto:insurancedocuments.fssa@fssa.in.gov

Additionally, the Contractor’s Division of Supplier Diversity (“DSD”) ongoing obligations have been updated as detailed in the IDOA DSD Letter of Dete rmination, 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 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:

IVB PHONE COMPANY

NAME

SCOPE OF

PRODUCTS and/or

SERVICES

UTILIZATION

DATE

PERCENT

IVOSB (317) 605-

Patriot Ventures, LLC. d.b.a Patriot

Insurance and

Risk

Management

Services

Provide strategic benefit planning and management of reinsurance transactions

1/1/23-12/31/26 0.03%

IVOSB (410) 533-

Vespa Group Provide recruiting, staffing, and resource management needs and IT support

1/1/23-12/31/26 3.78%

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 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.

Docusign Envelope ID: FF0CFB9D-3DFE-4B3A-B000-4D7FF09FEC38 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 is changed to remove the IDOA-certified MBE LCP Transportation, LLC and add the IDOA -certified

MBE Professional Management Enterprises, Inc. at 13.88%. The change results in a 0% change in overall commitment obligated for both Minority Business Enterprises

Compliance and Women’s Business Enterprises Compliance. Therefore Clause 32 is modified 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

MBE (317) 493-

Bucher & Christian

Consulting, Inc.

d.b.a BCforward

Provide vendor management services

1/1/23-12/31/26 0.51%

WBE (844) 366-

Clover Senior

Care

Provide home care visits for new members to assist completing health needs screenings, social determinants of health screenings, and potential gaps in care

1/1/23-12/31/26 0.86%

WBE (317) 571-

Coles Marketing

Communications, Inc.

Provide marketing consulting services, graphic design, medical relations services, staffing and advertising buy services

1/1/23-12/31/26 1.89%

WBE (317) 634-

Colored Threads Provide consulting on and supply of promotional items for community outreach and small incentive items

1/1/23-12/31/26 0.01%

MBE (404) 610-

CulturaLink, Inc. Provide interpreters to deliver culturally

1/1/23-12/31/26 0.14% competent care

WBE (317) 283-

Engaging

Solutions, LLC

Provide staffing for outbound member education/outreach calls and inbound member calls

1/1/23-12/31/26 3.04%

MBE (317) 872-

Fineline Graphics d.b,a Fineline

Printing Group

Provide printing and mailing services and promotional merchandising services

1/1/23-12/31/26 0.30%

MBE (317) 926-

Indiana Minority

Health Coalition, Inc. d.b,a IMHC

Provide outreach, training, maternal/child support services, and health equity fund development

1/1/23-9/26/23 1.39%

MBE (317) 926-

Indiana Minority

Health Coalition, Inc. d.b,a IMHC

Provide outreach, training, maternal/child support services, and health equity fund development

9/27/23-12/31/26 1.182%

WBE (317) 896-

Keith Marketing

Group

Provide marketing services

1/1/23-12/31/26 0.02%

MBE (317) 291-

LCP

Transportation, LLC

Provide unlimited transportation services for members

1/1/23-3/7/24 16.28%

MBE (317) 291-

LCP

Transportation, LLC

Provide unlimited transportation services for members

3/8/24-7/7/25 13.88%

MBE (317) 541-

Professional

Management

Enterprises, Inc.

Provide professional staffing services

7/8/25-12/31/26 13.88%

WBE (317) 218-

RepuCare, Inc. Provide recruiting, staffing, resource management needs

1/1/23-12/31/26 1.69%

WBE (812) 369-

RoBailey

Consulting, LLC

Provide consulting services with IHCP government program policies and regulations knowledge and

1/1/23-12/31/26 3.11% experience

MBE (317) 922-

Sahasra

Technologies Corp dba STLogics

Provide Chat Bot functionality to enhance customer service

1/1/23-12/31/26 0.30%

MBE (317) 258-

Black Onyx

Management, Inc.

Provide outreach, training, maternal/child support services, and health equity fund development

9/27/23-12/31/26 .203%

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 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 superseded and replaced by:

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 mailto:MWBECompliance@idoa.IN.gov mailto:MWBECompliance@idoa.IN.gov http://www.in.gov/idoa/mwbe/payaudit.htm mailto:cora.steinmetz@fssa.in.gov

B. Notices to the Contractor shall be sent to:

Christina Hage, Chief Executive Officer

Coordinated Care Corporation d/b/a Managed Health Services d/b/a MHS 429 N. Pennsylvania Ave Indianapolis, Indiana 46204

Email: Christina.I.Hage@mhsindiana.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 #1-3 and not affected by this Amendment shall remain in full force and effect.

mailto:Kevin.M.OToole@mhsindiana.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.

COORDINATED CARE CORPORATION Indiana Family and Social Services Administration d/b/a Managed Health Services 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) Warren Lenard, Executive Director

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

12/23/2025 | 15:52 EST

Plan President & CEO Deputy Secretary

12/23/2025 | 12:57 PST

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

EXHIBIT 1D

SCOPE OF WORK – HOOSIER HEALTHWISE

Table of Contents

1.0 Background

2.0 Administrative Requirements

2.1 State Licensure and Compliance with Applicable Laws, Rules, and Regulations

2.2 National Committee for Quality Assurance (NCQA) Accreditation

2.3 Administrative and Organizational Structure

2.3.1 Staffing

2.3.2 Key Staff

2.3.3 Other Required Staff Positions

2.3.4 Suggested Staff Positions

2.3.5 Staff Training and Qualifications

2.3.6 Debarred Individuals

2.4 FSSA Meeting Requirements

2.5 Financial Stability

2.5.1 Solvency

2.5.2 Insurance Requirements

2.5.3 Reinsurance

2.5.4 Financial Accounting Requirements

2.5.5 Reporting Transactions with Parties of Interest

2.5.6 Medical Loss Ratio (MLR)

2.5.7 Reserved

2.6 Subcontracts

2.7 Confidentiality of Member Medical Records and Other Information

2.8 Internet Quorum (IQ) Inquiries

2.9 Material Change to Operations

2.10 Future Program Guidance

2.11 Conflict of Interest

2.12 Capitation Related to a Vacated Program

2.13 Maintenance of Records

2.14 Maintenance of Written Policies and Procedures

2.15 Participation in Readiness Review

2.16 Dissemination of Information

2.17 FSSA Ongoing Monitoring

3.0 Covered Benefits and Services

3.1 Covered Benefits and Services

3.2 Self-referral Services

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

3.4 Drug Coverage

3.4.1 Drug Rebates

3.4.2 SUPDL and Formulary Requirements

3.4.3 DUR Board and MHQAC Reporting Requirements

3.4.4 Dispensing and Monitoring Requirements

3.4.5 E-Prescribing

3.4.6 Carve-Out of Select Drugs

3.4.7 340B

3.4.8 Pharmacy Continuity of Care

3.4.9 SUPPORT Act Compliance

3.4.10 Diabetes Supplies Coverage

3.4.11 Required Copayments for Package C Members

3.5 Smoking Cessation and Tobacco Dependence Treatment

3.6 Emergency Care

3.6.1 Post-Stabilization Services

3.6.2 Emergency Room Services Co-Payment – Hoosier Healthwise

3.7 Behavioral Health

3.7.1 Behavioral Health Care Services

3.7.2 Behavioral Health Provider Network

3.7.3 Case Management for Members Receiving Behavioral Health Services

3.7.4 Behavioral Health Care Coordination

3.7.5 Behavioral Health Continuity of Care

3.7.6 Institution for Mental Disease (IMD)

3.8 Care Coordination

3.8.1 Member Assessment

3.8.2 Stratification & Level of Service

3.8.3 Care Plan Development

3.8.4 Reassessments

3.9 Twenty-Four (24)-hour Nurse Call Line

3.10 Other Covered Benefits and Services

3.11 Carved-out Services

3.11.1 Medicaid Rehabilitation Option (MRO) Services

3.11.2 1915(i) State Plan Home and Community-Based Services

3.11.3 Individualized Family Services Plan (IFSP) services

3.11.4 Individualized Education Plan (IEP) services

3.12 Excluded Services

3.12.1 Long-Term Institutional Care

3.12.2 Hospice

3.12.3 1915(c) Home-and-Community-Based Services (HCBS) Waiver

3.12.4 Psychiatric Treatment in a State Hospital

3.12.5 Psychiatric Residential Treatment Facility (PRTF) Services

3.13 Continuity of Care

3.14 Out-of-Network Services

3.14.1 Out-of-Network Provider Reimbursement

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

3.15 Enhanced Services

3.16 Opioid Treatment Program (OTP)

3.17 Dental Services

3.18 Non-Emergency Medical Transportation Services

3.19 Residential Substance Use Disorder (SUD) Services

4.0 Member Services

4.1 Marketing and Outreach

4.2 Member Enrollment and Contractor Selection

4.2.1 Enrollment and Practice Discrimination

4.2.2 Enrollment Packet

4.2.3 PMP Selection

4.2.4 Provider Network Information

4.2.5 Children with Special Health Care Needs

4.2.6 Member Disenrollment from MCE

4.3 Member-Contractor Communications

4.3.1 Member Services Helpline and twenty-four (24)-Hour Nurse Line

4.3.2 Electronic Communications

4.4 Member Information, Education and Outreach

4.4.1 Additional Information Available Upon Request

4.4.2 Member and Stakeholder Education and Engagement

4.4.3 Member Handbook

4.4.4 Member Website

4.4.5 Preventive Care Information

4.4.6 Member Education

4.4.7 Cost and Quality Information

4.5 Member and Potential Member Communications Review and Approval

4.6 Redetermination Assistance

4.7 Member-Provider Communications

4.8 Member Rights

4.9 Member Grievances and Appeals

4.9.1 Contractor Grievance and Appeals Policies

4.9.2 Inquiry Processing Requirements

4.9.3 Grievance Processing Requirements

4.9.4 Appeals Processing Requirements

4.9.5 External Review by Independent Review Organization

4.9.6 State Fair Hearing Process

4.9.7 Continuation of Benefits Pending Appeal & Reinstatement of Benefits

4.9.8 Member Notice of Grievance, Appeal and Fair Hearing Procedures

4.9.9 Recordkeeping Requirements of Grievances and Appeals

4.10 Oral Interpretation Services

4.11 Health Equity

4.12 Advance Directive Information

5.0 Provider Network Requirements

5.1 Network Development

5.1.1 Access to Culturally and Linguistically Competent Providers

5.2 Network Composition Requirements

5.2.1 Acute Care Hospital Facilities

5.2.2 Primary Medical Providers (PMP)

5.2.3 Specialist and Ancillary Providers

5.2.4 Pharmacy Services

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

5.2.6 Inpatient Psychiatric Facilities

5.2.7 SUD Providers

5.2.8 Dental Providers

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

5.2.10 School-based Health Care Services

5.2.11 Indian Healthcare Providers

5.2.12 County Health Departments

5.2.13 Urgent Care Clinics

5.2.14 Dialysis Treatment Center

5.2.15 OB/GYNs

5.2.16 Non-emergency Medical Transportation Providers

5.3 Provider Enrollment and Disenrollment

5.4 Provider Agreements

5.5 Provider Credentialing

5.6 Medical Records

5.7 Provider Education and Outreach

5.7.1 Provider Communications Review and Approval

5.7.2 Provider Policy and Procedures Manual

5.8 Contractor Communications with Providers

5.8.1 Provider Website

5.8.2 Provider Services Helpline

5.8.3 IHCP Roadshows and Seminars

5.8.4 Provider Welcome Letter

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

5.10 Member Payment Liability

5.11 Provider Directory

5.12 Hospital Assessment Fee

5.13 Physician Faculty Access to Care (PFAC) Program

5.14 State-directed Applied Behavioral Analysis (ABA) Reimbursement

6.0 Quality Assessment and Performance Improvement/Utilization Management

6.1 Quality Management and Improvement Program

6.1.1 Quality Assessment and Performance Improvement Committee

6.1.2 Quality Assessment and Performance Improvement Program Work Plan

Requirements

6.1.3 External Quality Review

6.2 Incentive Programs

6.2.1 Provider Incentive Programs

6.2.2 Member Incentive Programs

6.2.3 Notification of Pregnancy (NOP) Incentives

6.3 Utilization Management Program

6.3.1 Authorization of Services and Notices of Actions

6.3.2 Objection on Moral or Religious Grounds

6.3.3 Utilization Management Committee

7.0 Program Integrity

7.1 Program Integrity Plan

7.2 Program Integrity Operations

7.3 Program Integrity Reporting

7.4 Program Integrity Overpayment Recovery

7.5 Auditing Program Integrity Operations

8.0 Information Technology (IT) Systems

8.1 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 - Hoosier Healthwise Package A

8.7.2 Coordination of Benefits - Hoosier Healthwise, Package C (CHIP)

8.7.3 Collection and Reporting

8.7.4 Cost Avoidance

8.7.5 Retroactive Medicare Coverage

8.7.6 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 Reports

9.7 Claims Reports

9.8 CMS Reporting

9.9 Other Reporting

10.0 Failure to Perform/Non-compliance Remedies

10.1 Non-compliance Remedies

10.2 Evidence of Financial Responsibility

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 Healthwise (HHW) program. The

State is looking to contract on a statewide basis with managed care entities (MCEs) with a demonstrated capacity to actively manage care for this low-income population.

Because Hoosier Healthwise 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/ihcp-provider-enrollment -transactions/

Unless otherwise indicated, the requirements set forth in this Scope of Work apply to the Contractor’s responsibilities under the Hoosier Healthwise program.

1.0 Background

The Office of Medicaid Policy and Planning (OMPP) of the Indiana Family and Social Services Administration (FSSA) manages the Hoosier Healthwise program. For purposes of this Scope of

Work, the term “FSSA” shall refer to the agency and its divisions, including, but not limited to OMPP. Hoosier Healthwise is a Medicaid program that helps approximately six hundred thousand (600,000) Hoosiers.1 The program’s aim is to provide comprehensive health care coverage for

Hoosier families.

The Contractor shall perform the administrative functions of a typical insurer, as well as address the unique challenges of low-income children and families and can manage and integrate care along the continuum of health care services. Goals for Hoosier Healthwise include:

Creating processes that efficiently stratify one hundred percent (100%) of the HHW member population into appropriate services and provide early identification of enrollees who have or may have special health needs.

Developing data collection methods that utilize information specific to gender, ethnicity, race, region, and primary language to guide annual health equity efforts.

Collaborating with network providers, local health departments, and additional State agencies to create activities that address infant and maternal mortality.

Implementing strategies to increase the number of eligible HHW members who receive a

Developmental Screening aged zero (0) to three (3) by five percent (5%) quarterly.

Quarterly increasing the percentage of HHW members aged two (2) to three (3) who have received at least one (1) dental visit by five percent (5%).

Quarterly increasing the percentage of HHW members who have received a lead test at age one (1) by five percent (5%).

Annually increasing the percentage of HHW members who receive two (2) influenza (flu) vaccines by age two (2) by ten percent (10%).

1 The enrollment f igures provided in this Scope of Work are estimates only. Enrollment in the Hoosier Healthw ise 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/ihcp-provider-enrollment-transactions/

The Contractor shall ensure that they follow all program requirements as described in the Hoosier Healthwise MCE Policies and Procedures Manual as updated and amended periodically.

2.0 Administrative Requirements

2.1 State Licensure and Compliance with Applicable Laws, Rules, and Regulations

Prior to the Contract effective date, and as verified in the readiness review, 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., Prior Authorization/Utilization Management

(PA/UM) criteria; claims processing; encounter data submission; etc.), regardless of geographic location.

The Contractor shall comply with all applicable Federal and State laws and regulations including Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); Title XXI of the Social Security Act; the

Age Discrimination Act of 1975; the Rehabilitation Act of 1973 (regarding education programs and activities), and the Americans with Disabilities Act of 1990 as amended; section 1557 of the Patient Protection and Affordable Care Act per 42 CFR 438.3(f)(1) and 42 CFR

438.100(d).

2.2 National Committee for Quality Assurance (NCQA) Accreditation

As required by IC 12-15-12-21, the Contractor shall be accredited by the National Committee for Quality Assurance (NCQA) on or before the Contract start date. When accreditation standards conflict with the standards set forth in the Contract, the Contract prevails, unless the accreditation standard is more stringent.

Per 42 CFR 438.332(b), The Contractor must authorize NCQA to provide the State 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 Administrative and Organizational Structure

The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its Hoosier Healthwise members. The Contractor’s organizational structure shall support collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements.

Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the

Contract (i.e., data submission, data transmissions, reporting formats, etc.).

The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all Hoosier Healthwise program requirements and standards. The Contractor shall not be located outside of the United States per 42 CFR 438.602(i). The Contractor shall manage the functional linkage of the following major operational areas:

Administrative and fiscal management

Member services

Provider services

Marketing

Provider enrollment

Network development and management

Quality management and improvement

Utilization management

Clinical assessment, disease management, care management and complex case management Special investigations and waste, fraud and abuse detection

Behavioral and physical health

Information systems

Performance data reporting and encounter claims submission

Claims payments

Grievances and appeals

2.3.1 Staffing

The Contractor shall have in place sufficient administrative, clinical staff and organizational components to comply with all program requirements and standards. The Contractor shall maintain a high level of Contract performance and data reporting capabilities regardless of staff vacancies or turnover. The

Contractor shall have an effective method to address and minimize staff turnover (e.g., cross training, use of temporary staff or consultants, etc.) as well as processes to solicit staff feedback to improve the work environment. These processes will be verified during the readiness review.

The Contractor shall have position descriptions for the positions discussed in this section that include the responsibilities and qualifications of the position such as, but not limited to: education (e.g., high school, college degree or graduate degree), professional credentials (e.g., licensure or certifications), work experience, membership in professional or community associations, etc.

2.3.2 Key Staff

The Contractor shall employ the key staff members listed below. The State requires the Contractor to have key staff members dedicated full-time to the

Contractor’s Indiana Medicaid product lines. In some instances, key staff must be dedicated to Hoosier Healthwise. The Contractor must employ sufficient staff to achieve compliance with contractual requirements and performance metrics.

The Contractor shall establish and maintain a business office or work site within five miles of downtown Indianapolis, Indiana. All key staff must reside in Indiana, and all other staff must perform the majority of their work within Indiana unless explicitly exempted by the Contract. Additionally, key personnel must physically carry out the majority of their daily responsibilities from this location, ensuring a significant portion of the Contractor’s operations are based there. The Contractor must provide documentation upon request to verify compliance with these requirements. The Contractor shall be responsible for all costs related to securing and maintaining the facility for interim start-up support and the subsequent operational facility.

Upon award of the Contract, the Contractor shall deliver the final staffing plan within thirty (30) calendar days after notice of award; such plan will include a resume for each proposed key staff person outlined below for acceptance by FSSA. Per 42 CFR 455.104(b)(4), the Contractor shall submit the name, address, date of birth, and SSN of any managing employee of the Contractor.

FSSA reserves the right to approve or disapprove all initial and replacement key staff prior to their assignment to Hoosier Healthwise. FSSA shall have the right to require that the Contractor remove any individual (whether or not key staff) from assignment to the program.

The Contractor shall ensure the location of any staff or operational functions outside of the State of Indiana does not compromise the delivery of integrated services and the seamless experience for members and providers. The Contractor shall be responsible for ensuring all staff functions conducted outside of the State of Indiana are readily reportable to FSSA at all times to ensure such locations does not hinder the State’s ability to monitor the Contractor’s performance and compliance with Contract requirements. Indiana-based staff shall maintain a full understanding of the operations conducted outside of the State of Indiana, and must be prepared to discuss these operations with FSSA upon request, including during unannounced FSSA site visits.

Except in the circumstance of the unforeseeable loss of a key staff member’s services, the Contractor shall provide written notification to FSSA of anticipated vacancies of key staff within five (5) business days of receiving the key staff person’s notice to terminate employment or five (5) business days before the vacancy occurs, whichever occurs first. At that time, the Contractor shall present FSSA with an interim plan to cover the responsibilities created by the key staff vacancy. Likewise, the Contractor shall notify FSSA in writing within five (5) business days after a candidate’s acceptance to fill a key staff position or five (5) business days prior to the candidate’s start date, whichever occurs first.

In addition to attendance at vendor meetings, all key staff must be accessible to FSSA and its other program subcontractors via telephone, voicemail and electronic mail systems. As part of its annual and quarterly reporting, the

Contractor must submit to FSSA an updated organizational chart including e-mail addresses and phone numbers for key staff.

FSSA reserves the right to interview any prospective candidate and/or approve or deny the individuals filling the key staff positions set forth below. FSSA also reserves the right to require a change in key staff as part of a corrective action plan should performance concerns be identified.

The key staff positions required under the Contract include:

Chief Executive Officer, President, or Executive Director – The Chief Executive Officer or Executive Director has full and final responsibility for plan management and compliance with all provisions of the Contract.

Chief Financial Officer – The Chief Financial Officer shall oversee the budget and accounting systems of the Contractor for the Hoosier Healthwise program.

This Officer shall, at a minimum, be responsible for ensuring that the Contractor meets the State’s requirements for financial performance and reporting.

Compliance Officer – The Contractor shall employ a Compliance Officer who is accountable to the Contractor’s executive leadership and dedicated full-time to the Contractor’s Indiana Medicaid product lines. This individual will be the primary liaison with the State (or its designees) to facilitate communications between FSSA, the State’s contractors and the Contractor’s executive leadership and staff. This individual shall maintain a current knowledge of federal and state legislation, legislative initiatives and regulations that may impact the Hoosier

Healthwise program. It is the responsibility of the Compliance Officer to coordinate reporting to the State as defined in Section 9.0 and to review the timeliness, accuracy and completeness of reports and data submissions to the

State. The Compliance Officer, in close coordination with other key staff, has primary responsibility for developing and implementing policies, procedures, and practices designed to ensure all Contractor functions are in compliance with the terms of the Contract. The Compliance Officer shall meet with the OMPP Program Integrity Unit on a quarterly basis.

Chief Information Officer (CIO) or Information Technology (IT) Director –

The Contractor shall employ a CIO or IT Director who is dedicated full-time to the Contractor’s Indiana Medicaid product lines. This individual will oversee the Contractor’s Hoosier Healthwise Information Technology (IT) systems and serve as a liaison between the Contractor and the State fiscal agent or other FSSA contractors regarding encounter claims submissions, capitation payment, member eligibility), enrollment and other data transmission interface and management issues. The CIO or IT Director, in close coordination with other key staff, is responsible for ensuring all program data transactions are in compliance with the terms of the Contract. The CIO or IT Director is responsible for attendance at all Technical Meetings called by the State. If the CIO or IT Director is unable to attend a Technical Meeting, the CIO or IT Director shall designate a representative to take his or her place. This representative shall report back to the CIO or IT Director on the Technical Meeting’s agenda and action items. For more information on the IT program requirements, see Section 8.0.

Medical Director – The Contractor shall employ the services of a Medical

Director who is an Indiana-licensed Indiana Health Care Provider (IHCP) provider board certified in family medicine or internal medicine. If the Medical Director is not board certified in family medicine, they shall be supported by an Indiana licensed clinical team with experience in pediatrics, behavioral health, adult medicine and obstetrics/gynecology. The Medical Director shall be dedicated full -time to the Contractor’s Indiana Medicaid product lines. The Medical Director shall oversee the development and implementation of the Contractor’s disease management, case management and care management programs; oversee the development of the Contractor’s clinical practice guidelines; review any potential quality of care problems; oversee the Contractor’s clinical management program and programs that address special needs populations; oversee health screenings; serve as the Contractor’s medical professional interface with the

Contractor’s primary medical providers (PMPs) and specialty providers; and direct the Quality Improvement and Utilization Management programs, including, but not limited to, monitoring, corrective actions and other quality improvement, utilization management or program integrity activities. The Medical Director, in close coordination with other key staff, is responsible for ensuring that the medical management and quality improvement components of the Contractor’s operations are in compliance with the terms of the Contract. The Medical Director shall work closely with the Pharmacy Director to ensure compliance with pharmacy-related responsibilities set forth in Section 3.4. The Medical Director shall attend all FSSA quality meetings, including the Quality Strategy Committee meetings and Subcommittee meetings. If the Medical Director is unable to attend an OMPP quality meeting, the Medical Director shall designate a representative to take their place. This representative must report back to the Medical Director on the meeting’s agenda and action items. The Medical Director shall be responsible for knowing and taking appropriate action on all agenda and action items from all OMPP quality meetings.

Member Services Manager – The Contractor shall employ a Member Services Manager who is dedicated full-time to member services for the Contractor’s

Indiana Medicaid product lines, which shall be available via the member helpline and the member website, including through a member portal. The Member Services Manager shall, at a minimum, be responsible for directing the activities of the Contractor’s member services, including, but not limited to, member helpline telephone performance, member e-mail communications, member education, the member website, member outreach programs, development, approval and distribution of member materials. The Member Services Manager manages the member grievances and appeals process, and works closely with other managers (especially, the Quality Improvement Manager, Utilization

Manager and Medical Director) and departments to address and resolve member grievances and appeals. The Member Services Manager shall oversee the interface with the Enrollment Broker regarding such issues as member enrollment and disenrollment, member PMP assignments and changes, member eligibility and newborn enrollment activities. The Member Services Manager shall provide an orientation and on-going training for member services helpline representatives, at a minimum, to support accurately informing members of how the Contractor operates, availability of covered services, benefit plans and limitations, health screenings, emergency services, PMP assignment and changes, specialty provider referrals, self-referral services, preventive and enhanced services, well-child services and member grievances and appeals procedures. The Member Services Manager, in close coordination with other key staff, is responsible for ensuring that all of the Contractor’s member services operations are in compliance with the terms of the Contract. For more information regarding the member services program requirements, see Section 4.0.

Provider Services Manager – The Contractor shall employ a Provider Services Manager who is dedicated full-time to the Contractor’s Indiana Medicaid product lines. The Provider Services Manager shall, at a minimum, be responsible for the provider services helpline performance, provider recruitment, contracting and credentialing, facilitating the provider claims dispute process, developing and distributing the provider manual and education materials and developing outreach programs.