503MHS23HIP AM04 69655.pdf

AMENDMENT #4

CONTRACT #0000000000000000000069655

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 Coordinated Care

Corporation d/b/a Managed Health Services (the "Contractor"), approved by the last State Signatory on March 1, 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 Healthy Indiana Plan program is hereby amended to update Exhibits 1.B, 2.B, 5.B, and 6.B. Unless otherwise noted, and subject to specific provisions within each Exhibit, this amendment shall be effective January 1, 2026.

Exhibit 1.B, which outlines the Scope of Work, is hereby superseded and replaced by Exhibit

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

Exhibit 2.B, which outlines the Contract Compliance and Pay for Outcomes, is hereby superseded and replaced by Exhibit 2.C, which is attached hereto and incorporated herein.

Exhibit 5.B, which outlines the Contract Definitions, is hereby supersed ed and replaced by

Exhibit 5.C, 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Exhibit 6.B, which outlines the State’s Capitation Rates, is hereby superseded and replaced by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 $255,701,178.03 is being added to the total contract amount. Total remuneration under the Contract is not to exceed $4,429,692,542.65.

Clause 18. Employment Eligibility Verification is replaced and superseded by the following: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 empl oyed, 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: 3B6B628C-0BAF-49A8-881A-ED1F6343F965

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 replaced and superseded by the following:

27. Information Technology Enterprise Architecture Requirements.

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

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 Insurance is replaced and superseded by the following:

28. Insurance.

A. The Contractor and its subcontractors (if any) shall secure and keep in force during the term of this Contract the following insurance coverages (if applicable) covering the Contractor for any and all claims of any nature which may in any man ner 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.

5. Valuable Papers coverage, i f applicable, with an Inland Marine Policy Insurance with limits sufficient to pay for the re-creation and reconstruction of such records.

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

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

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

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

Additionally, Clause 33. Nondiscrimination is replaced and superseded by the following:

33. Nondiscrimination.

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

A. The Contractor covenants that it shall not discriminate against any employee or applicant for employment relating to this Contract with respect to the hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment, because of 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.

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:

mailto:insurancedocuments.fssa@fssa.in.gov

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.

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

Docusign Envelope ID: 3B6B628C-0BAF-49A8-881A-ED1F6343F965 mailto:IndianaVeteransPreference@idoa.IN.gov mailto:Indianaveteranspreference@idoa.IN.gov http://www.in.gov/idoa/mwbe/payaudit.htm

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 competent care

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

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 experience.

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

MBE (317) 922- Sahasra Provide Chat Bot 1/1/23-12/31/26 0.30%

0922 Technologies Corp dba STLogics functionality to enhance customer service

MBE (317) 258-

Black Onyx

Management, Inc.

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

9/27/2023-

12/31/2026

0.203%

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 Amendment. 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 Amendment.

The Contractor shall report payments made to Division of Supplier Diversity certified subcontractors under this Contract on a monthly basis us ing Pay Audit. The Contractor shall notify subcontractors that they must confirm payments received from Contractor in Pay Audit. The Pay Audit system can be accessed on the IDOA webpage at:

www.in.gov/idoa/mwbe/payaudit.htm. Contractor may also be required to report Division of Supplier Diversity certified subcontractor payments directly to the Division of Supplier Diversity, as reasonably requested and in the format required by the Division of Supplier Diversity.

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 replaced and superseded by the following:

34. Notice to Parties.

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

A. Notices to the State shall be sent to:

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

Director of the Office of Medicaid Policy and Planning

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

402 W. Washington Street, Room W461

Indianapolis, IN 46204

Email: mitch.roob@fssa.IN.gov

B. Notices to the Contractor shall be sent to:

Christina Hage, Chief Executive Officer mailto:MWBECompliance@idoa.IN.gov mailto:MWBECompliance@idoa.IN.gov http://www.in.gov/idoa/mwbe/payaudit.htm mailto:cora.steinmetz@fssa.in.gov

Coordinated Care Corporation, d.b.a. Managed Health Services 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.

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 & Social Services Administration

INDIANA 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

Plan President & CEO

12/23/2025 | 15:51 EST

Deputy Secretary

12/29/2025 | 18:28 PST

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

EXHIBIT 1C

SCOPE OF WORK – HEALTHY INDIANA PLAN

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

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

3.5 Smoking Cessation and Tobacco Dependence Treatment

3.6 Emergency Care

3.6.1 Post-Stabilization Services

3.6.2 Emergency Room Services Co-Payment – HIP

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 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

3.12 Excluded Services

3.12.1 Long-Term Institutional Care

3.12.2 1915(c) Home and Community-Based Services (HCBS) Waiver

3.12.3 Psychiatric Treatment in a State Hospital

3.12.4 Behavioral and Primary Healthcare Coordination (BPHC) Services

3.12.5 Psychiatric Residential Treatment Facility (PRTF) Services

3.13 Continuity of Care

3.14 Out-of-Network Services

3.15 Out-of-Network Provider Reimbursement

3.16 Enhanced Services

3.17 Member Cost-Sharing Limits

3.18 Opioid Treatment Program (OTP)

3.19 Dental Services

3.20 Non-Emergency Medical Transportation Services

3.21 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 HIP 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 Indian Healthcare Providers

5.2.11 County Health Departments

5.2.12 Urgent Care Clinics

5.2.13 Dialysis Treatment Center

5.2.14 OB/GYNs

5.2.15 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

5.7.3 Education for HIP Providers

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 . 165

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

5.15 Reimbursement for Nursing Facilities

6.0 Quality Assessment and Performance Improvement / Utilization Management

6.1 Quality Assessment and Performance Improvement Program

6.1.1 Quality Assessment and Performance Improvement Committee

6.1.2 Quality Management and 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

8.7.2 Collection and Reporting

8.7.3 Cost Avoidance

8.7.4 Retroactive Medicare Coverage

8.7.5 Cost Avoidance Exceptions

8.8 Health Information Technology and Interoperability

9.0 Performance Reporting and Incentives

9.1 Administrative and Financial Reports

9.2 Member Service Reports

9.3 Network Development Reports

9.4 Provider Service Reports

9.5 Quality Management Reports

9.6 Utilization Reports

9.7 Claims Reports

9.8 HIP Reports

9.9 CMS Reporting

9.10 Unclaimed Refunds or Property Report

9.11 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

12.0 HIP Plan Design and Member Eligibility

12.1 HIP Plus

12.1.1 Low Income Adults

12.2 HIP Basic

12.2.1 HIP Basic Potential Plus

12.2.2 Low Income Adults

12.3 HIP State Plan

12.3.1 Low Income Adults

12.3.2 Medically Frail

12.4 Pregnancy Coverage under HIP

13.0 Billing and Collections

13.1 Individual Cost-Sharing Obligations

13.1.1 HIP Plus Member Cost-Sharing

13.1.2 HIP Basic Member Cost-Sharing

13.1.3 HIP State Plan Member Cost-Sharing

13.1.4 Exempt Populations

13.1.5 Tobacco Surcharge

13.2 State POWER Account Contributions

13.3 Third Party POWER Account Contributions

13.4 Recalculations

13.5 Billing and Collections

13.5.1 Payment Methods

13.5.2 Employer and Other Third-Party POWER Account Contributions

13.6 Enrollment and Initial POWER Account Contributions

13.6.1 Standard Enrollment

13.6.2 Fast Track Enrollment

13.7 Non-Payment of Monthly POWER Account Contribution

13.7.1 Non-Payment Penalty Exceptions

13.7.2 Disenrollment Exceptions

14.0 Personal Wellness & Responsibility (POWER) Accounts

14.1 POWER Account Administration

14.2 Use of POWER Account Funds

14.3 Provider Reimbursement and the POWER Account

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

14.4 POWER Account Balance Information

14.5 Interest

14.6 Audit Requirement

14.7 Member 12 Month Eligibility Period

14.8 Rollover

14.8.1 Recalculation of Member Contributions

14.8.2 POWER Account Rollover

14.8.3 Recommended Preventive Care Services

14.8.4 POWER Account Reconciliation

14.9 Termination of Eligibility

14.9.1 Terminated Member Refund

14.9.2 Member Refunds Due to Members with Continuous Coverage

14.9.3 State Refund

14.9.4 POWER Account Reconciliation

14.10 POWER Account Debt Collection Process

14.11 POWER Account Balance Transfers

14.12 POWER Account Systems

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 Healthy Indiana Plan (HIP) 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 a low-income population.

Because HIP 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.

Unless otherwise indicated, the requirements set forth in this Scope of Work apply to the

Contractor’s responsibilities under the HIP program.

1.0 Background

The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and

Planning (OMPP) manages the HIP 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. HIP is one of the Medicaid programs that helps over three hundred ninety thousand (390,000) Hoosiers.1

HIP aims to provide comprehensive health care coverage for Hoosier families.

A brief description of the HIP program is outlined below. The HIP program seeks not only to provide health coverage to an uninsured population, but to improve health, promote prevention and encourage healthy lifestyles.

The Contractor shall perform the administrative functions of a typical insurer, address the unique challenges of low-income populations, and manage and integrate care along the continuum of health care services. Goals for the HIP program include:

Improve health outcomes;

Promote primary and preventive care;

Foster personal responsibility and healthy lifestyles;

Assure the appropriate use of health care services;

Develop informed health care consumers by increasing health literacy and providing price and quality transparency;

Improve access to health care services;

Encourage quality, continuity and appropriateness of medical care;

Deliver coverage cost-effectively;

Identify Medically Frail members and provide effective disease management, case management and care management programs for those that would benefit from such services;

Coordinate health and social services;

Integrate physical and behavioral health services;

Develop innovative member and provider incentives;

Use technology to ease administrative burden and help accomplish program goals;

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

1 The enrollment f igures provided in this Scope of Work w ere current as of January 2020. Enrollment in the HIP program may increase or decrease based upon federal policies, program priorities, available funding, etc.

Emphasize communication, training and collaboration with network providers; and

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

The Healthy Indiana Plan (HIP) is a program created to provide health care coverage to low-income adults. Indiana offers HIP members a comprehensive benefit package through a high deductible health plan paired with a personal health care account called a POWER (Personal

Wellness and Responsibility) Account. The health plan is subject to a two thousand five hundred dollar ($2,500) deductible and includes “first dollar” coverage for Affordable Care Act (ACA) required preventive services. Services considered preventive but not required by the ACA may be provided at five hundred dollars ($500) first dollar coverage per year. For purposes of clarification, MCEs may cap first dollar preventive services at five hundred dollars ($500) per year, but shall provide all required ACA preventive services first dollar as required by the ACA. The preventive services benefit is designed to help eliminate barriers to obtaining preventive care. Indiana offers HIP members comprehensive benefits in several benefit packages (HIP Plus, HIP Basic, HIP State Plan, and HIP Maternity) as described in Section 3.0 and Section 12.0. A description of the

HIP covered services is set forth in Exhibit 3.B of the Contract.

The POWER Account is modeled in the spirit of a traditional Health Savings Account (HSA) and is funded with state and individual contributions. Employers and other third parties may also contribute.

Members use POWER Account funds to meet the two thousand five hundred dollar ($2,500) deductible. POWER Accounts are funded with post-tax dollars and are not considered HSAs or other health spending accounts (e.g., Flexible Spending Accounts, Health Reimbursement Accounts, etc.) under federal law. Therefore, they are not subject to regulation under the U.S. Tax Code as such.

Members who consistently make required contributions to their POWER account will maintain access to the “HIP Plus” benefit plan that includes enhanced benefits such as dental, vision, and chiropractic manipulation coverage.

Members with income at or below one hundred percent (100%) of the federal poverty level (FPL)2 who do not to make monthly POWER account contributions will be placed in the “HIP Basic” plan, a more limited benefit plan. The HIP Basic plan maintains essential benefits, but incorporates reduced benefit coverage and a more limited pharmacy benefit. The HIP Basic plan will require co-payments for most services rather than the monthly POWER account contributions required of the HIP Plus plan. Except in limited circumstances, members with income above one hundred percent (100%) FPL will not have access to the HIP Basic plan, but will instead be terminated from the program. Contractor shall ensure that they follow all program requirements as described in the HIP 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 shall be:

An Indiana-licensed accident or sickness insurer; or

2All federal poverty levels listed in this Scope of Work are calculated based on the Modif ied Adjusted Gross Income (MAGI), w hich allow s for a f ive percent (5%) income disregard.

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); 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 HIP populations. 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 HIP 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

POWER Account administration

POWER Account contribution collections

Information systems

Performance data reporting and encounter claims submission

Claims payments

Grievances and appeals

Pharmacy Benefits Management

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 particular key staff members dedicated full-time to the Contractor’s Indiana Medicaid product lines. Contractor shall 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 the Healthy Indiana Program. 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 do 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 shall 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 shall 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 shall submit to FSSA an updated organizational chart including e-mail addresses and phone numbers for key staff.

FSSA reserves the right to 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 HIP 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 Healthy Indiana Plan product line. 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 HIP 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 HIP 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, POWER Account administration, 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 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.